Dr Shaad Abqari Dept of Pediatrics Objectives of this brief talk How to define AFP How to evaluate a case of AFP Rehan a 3 year old Not able to walk ID: 1010788
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1. Clinical approach to Acute Flaccid Paralysis Dr Shaad Abqari Dept of Pediatrics
2. Objectives of this brief talk How to define AFPHow to evaluate a case of AFP
3. Rehan, a 3 year oldNot able to walkLimping and falling when made to walk
4. Priya, 6 year oldAsymmetry of the faceInability to close right eye leading to its soreness
5. Questions ??
6. Questions ??Mother what is wrong?Is it polio? Is it paralysis?Can it be treated?How?Will he run and play again?Will she have her beautiful face back?
7. Questions ?? Clinician What is wrong – muscle, nerve, myoneural jn, spinal cord?What is the likely underlying diseaseExtent of involvementProgressionTreatment Is it serious??? PrognosisCounsel
8. When there are so many queries………
9. When there are so many queries……… PRESSURE!!!
10. History and examinationMeticulous and religious
11. Case DefinitionIn the Global Polio Eradication Initiative (PEI), acute flaccid paralysis is defined as: Any child aged <15 years who has acute onset of flaccid weakness, or any case of paralytic illness in a person of any age when polio is suspected.
12. Acute: rapid progression of paralysis from onset to maximum paralysisFlaccid: loss of muscle tone, “floppy” – as opposed to spastic or rigidParalysis: weakness, power is reduced, loss of voluntary movement DTR? SENSATIONS? Any case meeting this definition--- thorough investigation ---- if the paralysis is caused by polio.
13. 13Index symptomsParalysis, paresis (weakness), including transient episodes. Flaccid (floppy) paralysisWeakness (of limb, of unclear origin, etc.) Frequent falls Gait disturbance (Limping) Cannot walk, etc.Inability to move any limb / part of the bodyBulbar involvement (Nasal regurgitation, Change in voice i.e. Hoarseness/ nasal twang, Facial palsy, difficulty in deglutition etc.)
14. 14Atypical AFPAs we approach eradication, more & more polio cases are showing atypical presentations.Atypical presentations include:Facial palsy;Hemiplegia;Transient paralysis;Wrist drop;Foot drop.
15. What causes AFP?
16. Where is the fault?Loss of power and tone Abnormal functioning of any part of motor unitMuscleNeuromuscular junctionPeripheral nerveAnterior horn cell
17. Common differential diagnosisMuscleMyoglobinuriaHypokalemiaNMJMyasthenia gravisbotulism NervesGBSDiphtheric neuropathyAnterior horn cellsPoliomyelitis
18. Polio – a brief introductionBy RNA virus – 3 serotyMan and ?Predisposing factorsSelectively damages motor system
19. CFAsymptomatic 95%Abortive 4%Non paralytic 1%Paralytic .01%
20. Non paralyticHeadache, nausea, vomiting, neck rigiditySigns – TripodKiss the kneeNeck rigidity
21. ParalyticSpinal- muscle weakness (AFP)Bulbar and bulbospinalPolio encephalitis – UMN signs may be present
22. Treatment Bed restPain reliefAvoid precipitantsNeutral positioningPhysiotherapyGood nursingRehabilitation – physical, emotional and psychological support
23. Differential Diagnosis of AFPDiagnosis PolioG B SyndromeTransverse myelitisTraumatic neuritisOnset 24 – 48 hrsHrs to daysHrs to 4 daysHrs to few daysFever High, at onsetNot commonRare commonFlaccidity Asym, proximalSym, distalSym, lower limbAsym DTRDec or ---, hyperreflexiaDec or -Sensation Myalgia and backacheCramps, ting ling, hypoanAnaesthesia lower limbPain gluteal regionCranial nBulbar, bulbospinalOften +--Resp involvBulbar, bulbospinalIn severe casesSometimes -CSFHigh WBC, N or inc proteinFew WBC, High proteinNNBladder dysfun-Transient +Never
24. 24Clinical dilemma…..AFP - Polio Vs other causes of Acute paralysisIssue resolved by having surveillance of all cases of Acute Flaccid paralysisAFP Vs Borderline AFPHow to resolve it?Solution: Investigate borderline cases too!!
25. 25When too much polio is around…..Non-AFP casesPolio casesTrue AFP casesBordeline/ambiguous AFP casesSurveillance sensitivity is adequate enough to detect 90% polio cases
26. 26When transmission is very low…..Non-AFP casesPolio casesTrue AFP casesBordeline/ambiguous AFP casesSurveillance sensitivity is not good enough & detects only 50% polio casesSensitivity increases and leads to nearly 100% detection of polio casesIf stool is collected from borderline or ambiguous cases…
27. 27Clinical Presentation of WPVNo. of WPV2006No. of WPV2007Clinical Poliomyelitis586 (86.7)757 (86.71)Only history of Paralysis24 (2.7)14 (1.60)Hemiplegia35 (5.2)54 (6.19)G.B.Syndrome6 (0.9)3 (0.34)Traumatic Neuritis4 (0.6)8 (0.92)Only Limp4 (0.6)1 (0.11)Acute Encephalitis3 (0.4)3 (0.34)Isolated Facial Palsy3 (0.4)19 (2.18)Isolated Neck Flop4 (0.6)5 (0.57)Post Diptheric Polyneuritis2 (0.23)Others7 (1.0)7 (0.80)Total676873 Analysis of initial clinical presentation of WPV 2006-2007
28. 28Hypotonic postures
29. 29 Foot Drop Right
30. 30 Hyper ExtensionRight Knee
31. 31Child with left Hemiplegia
32. 32 Paralysis Right Lower Limb
33. 33 Foot Drop Left
34. 34 Neck Flop
35. 35 Paresis BothLower Limbs
36. 36 Paresis BothLower Limbs
37. 37 Hemiplegia Rt
38. 38Right Facial Palsy
39. 39
40. 40
41. 41All cases to be reported with detailed address Irrespective of :- Cases seen in OPD / Casualty / Wards / going LAMA /DeathClinical diagnosis of the caseLocal or outstation patientsPatients coming directly to you or referred cases.Any doubtful, border line case or under investigation case to be first reported without waiting for final diagnosis. Where to report:SMOsDr. M.A.H. Azhar - 9837081773Dr Guljabeen Ara Sheikh - 9756211112Dr. Snehil Singh - 9690007821 Dr. Ng Boney Devi - 9639993335Nodal Officer of your Hospital ORDIO – 0571- 2523272ORNPSP Unit (Local) – 0571 – 2409749,, 2905853,So the expectations……
42. 42Rukhsar - The last polio case detected in India in Jan 2011In Feb 2012, WHO drops India from the list of Polio endemic countries Let she be the last case of WPV in India
43. THANK YOU