Clinical Features and Associated Findings

Nonparalytic or Preparalytic. As stated previously, the majority of poliovirus infections were asymptomatic or characterized by a nonspecific viral syndrome of malaise, myalgias, and low-grade fever.

Paralytic. Patients who developed paralytic poliomyelitis may initially have had clinical symptoms of fever, malaise, headache, and gastrointestinal or upper respiratory tract symptoms. These symptoms subsided, only to recur after several days in association with increasing signs of meningeal irritation, headache, and stiff neck. When the illness progressed to the paralytic form, muscle soreness was prominent, particularly in the back and neck. Patients who developed paralysis usually did so on the second to fifth day after meningeal signs and fever became evident. Once weakness began, it typically progressed for only the first few days after its onset. The fever persisted for several days but often subsided before the paralysis was complete. Patients complained of severe muscle pain and spasms with asymmetrical flaccid muscle weakness that usually affected a lower extremity. Severe bulbar weakness occurred in 10 to 15 percent of patients with paralysis. The disease was most common in infants and children between the ages of 6 months and 10 years, and was more common in the late summer and autumn months. Acute mortality usually resulted from respiratory or bulbar involvement. y

Postpolio Syndrome. The following criteria are necessary for a diagnosis of postpolio syndrome as the cause of progressive weakness: (1) a history of documented acute paralytic poliomyelitis in childhood or adolescence as evidenced by a well-documented acute febrile paralytic attack during a polio epidemic that resulted in residual lower motor neuron weakness; (2) partial recovery of motor function and functional stability or recovery for at least 15 years; (3) residual asymmetrical muscle atrophy with weakness, areflexia, and normal sensation in at least one limb; and (4) normal sphincteric function. y

Differential Diagnosis. Although the poliovirus now can be recovered from stool, throat washings, CSF, and blood, during the polio epidemic in this century virological confirmation was not available. The diagnosis was based on the clinical syndrome of fever with paralysis and residual lower motor neuron weakness. Examination of the CSF in the preparalytic stage showed an increase in the opening pressure and an increase in the white blood cell count that initially might be a predominance of polymorphonuclear leukocytes, but within a few days' time was characterized by a predominance of lymphocytes. White blood cell counts of 10 to 1000/mm3 were typically seen. The protein concentration in the CSF at the onset of illness might be normal or slightly increased. Patients who developed paralysis had a higher number of white blood cells in the CSF and a higher protein concentration than patients who did not develop paralysis. y

Needle examination shows a reduced number of voluntary motor unit potentials in the initial phase of paralysis, but in subsequent months, as the patient improves, the motor units become markedly enlarged, reflecting the reinnervation of the denervated muscle fibers.

Management. The management of patients with poliomyelitis and the postpolio syndrome is largely supportive. The treatment of bulbar poliomyelitis was significantly improved by the development of the "iron lung" in the 1930s. Patients with lower extremity weakness were initially treated with splints and plaster casts. Prolonged casting, often for months at a time, was typically employed. Eventually, the use of splinting and casting was replaced by physical therapy, braces, and other assistive ambulatory devices.y Anticholinesterase therapy has been beneficial in the treatment of symptoms of weakness and fatigue in patients with postpolio syndrome. y

The Advisory Committee on Immunization Practices (ACIP) of the United States Public Health Service has recommended that the United States adopt a sequential poliomyelitis immunization schedule--two doses of inactivated polio vaccine (IPV) followed by two doses of live oral polio vaccine (OPV). y , y At the present time, the World Health Organization recommends only OPV for both routine immunization and to achieve polio eradication. y , y Although OPV is among the safest of vaccines, one case of vaccine-associated polio occurs for every 2.5 million doses of OPV administered. The proposed sequential schedule recommended by the ACIP is a compromise that seeks to retain the advantages of OPV while preventing half of the 8 to 10 vaccine-related cases that occur every year in the United States. y

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