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Bulbar Poliomyelitis

Bulbar poliomyelitis is a specific type of an extremely rare viral paralytic disease in which the typical findings of acute flaccid paralysis are accompanied by bulbar symptoms - dysphagia, dysphonia, nasal regurgitation, as well as vascular and respiratory impairment in severe cases. The diagnosis rests on clinical criteria, microbiological studies that identify the poliovirus in samples (either polymerase chain reaction or antibody detection), but most importantly, confirming whether patients were vaccinated for polio.


Presentation

Through widespread vaccination, the global effort to eradicate polio has led to a marked decrease in the number of individuals suffering from poliomyelitis, a highly contagious infection caused by three distinct poliovirus serotypes, although serotype 1 is responsible for the majority of human cases [1] [2] [3] [4] [5]. Poliovirus belongs to the group of enteroviruses, and as a result, its mode of transmission involves the human gastrointestinal tract and the fecal-oral route [1] [2] [6]. Namely, poliomyelitis is established as a disease that solely affects human hosts and the majority of infections end in an asymptomatic fashion [1] [2] [4]. Once the virus reaches the human gastrointestinal (GI) tract, it is secreted in saliva in the first few days and in feces for a period of a few weeks, during which direct contact with secretions can result in transmission of the infection [1] [2]. Poliomyelitis, when symptomatic, can present in many forms, including abortive poliomyelitis (a milder type that presents with GI or flu-like symptoms and spontaneously resolves in approximately 7 days), aseptic meningitis (neck stiffness, and weakness in some cases, may accompany constitutional complaints), and paralytic poliomyelitis [1] [2] [6]. Bulbar poliomyelitis is considered to be one of the most severe and most fatal forms of paralytic poliomyelitis, due to the involvement of the brainstem neurons [1]. In addition to acute flaccid paralysis, bulbar poliomyelitis presents with dysphagia, dysphonia, nasal voice along with nasal regurgitation, as well as respiratory failure, autonomic nervous system dysfunction, and vasomotor disturbances (either hyper or hypotension or even vascular collapse) [2] [5]. Some authors describe a pure bulbar poliomyelitis without signs of weakness and limb paralysis [2].

Collapse
  • […] paralysis, bulbar poliomyelitis presents with dysphagia, dysphonia, nasal voice along with nasal regurgitation, as well as respiratory failure, autonomic nervous system dysfunction, and vasomotor disturbances (either hyper or hypotension or even vascular collapse[symptoma.com]
  • The loss of vasomotor control with circulatory collapse also contributes to high mortality. The encephalitic form of poliomyelitis This form is very rare and manifests as agitation, confusion, stupor, and coma.[emedicine.medscape.com]
  • Common biomechanical deficits in post polio Genu Recurvatum Knee flexion contracture Inadequate dorsiflexion in swing Dorsiflexion collapse in stance Genu valgum Mediolateral ankle instability Orthotic prescription Before prescribing orthosis it is necessary[physiotherapy-treatment.com]
Swelling
  • CDC vaccination schedule Polio vaccine prices for children On rare occasions these shots can cause mild or severe allergic reactions, such as: breathing problems high fever dizziness hives swelling of throat rapid heart rate Adults in the United States[healthline.com]
Aspiration
  • The essential indication for tracheotomy was secretional obstruction of the respiratory tract that could not be relieved by postural drainage and aspiration.[ncbi.nlm.nih.gov]
  • Other potential complications include pneumonia (including aspiration pneumonia ) and urinary tract infection.[patient.info]
Nasal Voice
  • In addition to acute flaccid paralysis, bulbar poliomyelitis presents with dysphagia, dysphonia, nasal voice along with nasal regurgitation, as well as respiratory failure, autonomic nervous system dysfunction, and vasomotor disturbances (either hyper[symptoma.com]
  • Dysphagia, nasal regurgitation, and nasal voice are usually the earliest signs of bulbar involvement, but some patients have pharyngeal paralysis and cannot control oral secretions.[merckmanuals.com]
Snoring
  • […] impaired intellectual function Sleep disturbances: – not feeling rested in the morning; – sleepiness during the day; – dreams of being smothered and/or nightmares; – restless and/or interrupted sleep; – fatigue or exhaustion from normal activities; snoring[post-polio.org]
Dysphagia
  • Bulbar poliomyelitis is a specific type of an extremely rare viral paralytic disease in which the typical findings of acute flaccid paralysis are accompanied by bulbar symptoms - dysphagia, dysphonia, nasal regurgitation, as well as vascular and respiratory[symptoma.com]
  • […] the poliovirus results in extensive damage to the motor neurons of the brainstem which control the respiratory system of the body as a result of which a child affected with Bulbar Polio is likely to experience severe breathing difficulties along with dysphagia[epainassist.com]
  • It can lead to respiratory muscle failure, distress of respiratory control, dysphagia, dysphonia and dysarthria. Cardiovascular, sweating and gut mobility disturbances may occur.[physiotherapy-treatment.com]
  • Bulbar paralysis with spinal involvement is more common in adults, most frequently involving the medulla and leading to dysphagia, dysphonia, respiratory failure, and vasomotor disturbance.[emedicine.medscape.com]
  • Dysphagia, nasal regurgitation, and nasal voice are usually the earliest signs of bulbar involvement, but some patients have pharyngeal paralysis and cannot control oral secretions.[merckmanuals.com]
Regurgitation
  • Bulbar poliomyelitis is a specific type of an extremely rare viral paralytic disease in which the typical findings of acute flaccid paralysis are accompanied by bulbar symptoms - dysphagia, dysphonia, nasal regurgitation, as well as vascular and respiratory[symptoma.com]
  • Dysphagia, nasal regurgitation, and nasal voice are usually the earliest signs of bulbar involvement, but some patients have pharyngeal paralysis and cannot control oral secretions.[merckmanuals.com]
  • […] may cause irregular respirations that appear interrupted and abnormal even to the point of falsely simulating intercostal or diaphragmatic weakness; (4) absence of effective coughing, shown by constant fatiguing efforts to clear the throat; (5) nasal regurgitation[easypediatrics.com]
Hypotension
  • […] addition to acute flaccid paralysis, bulbar poliomyelitis presents with dysphagia, dysphonia, nasal voice along with nasal regurgitation, as well as respiratory failure, autonomic nervous system dysfunction, and vasomotor disturbances (either hyper or hypotension[symptoma.com]
  • This may cause autonomic features - eg, hyper/hypotension, respiratory failure, and bulbar symptoms, such as dysphagia and dysphonia. Rarely, acute encephalitis can occur from poliovirus.[patient.info]
  • Occasionally, hypertension is followed by hypotension and shock and is associated with irregular or failed respiratory effort, delirium, or coma. This kind of bulbar disease may be rapidly fatal.[easypediatrics.com]
Hypertension
  • Hypertension and other autonomic disturbances are common in bulbar involvement and may persist for a week or more or may be transient.[easypediatrics.com]
Suggestibility
  • Comparison of mortality rates in this series with those of previous series in which tracheotomy was not done in the presence of similar indications, suggests that the procedure may be life-saving in a considerable percentage of cases.[ncbi.nlm.nih.gov]
  • For this reason, reports 1 2 3 on the Minnesota epidemic of 1946 divided the bulbar forms into various subdivisions and suggested that they consisted of not one but several distinct clinical and pathological entities.[nejm.org]
  • You may do so in any reasonable manner, but not in any way that suggests the licensor endorses you or your use. File history Click on a date/time to view the file as it appeared at that time.[commons.wikimedia.org]
  • There were many at that time who suggested that paralytic polio was an iatrogenic ( ed note -medically-caused) disease. The medical profession dropped tonsillectomy as if it were a hot potato, but I don't know that it told many about that.[whale.to]
  • Recent research suggests an immune system component in post polio syndrome (chronic low grade inflammation, triggered by polio virus debris).[poliotoday.org]
Urinary Retention
  • Fifty percent of adult patients with poliomyelitis experience transient acute urinary retention.[emedicine.medscape.com]
  • Common manifestations of paralytic poliomyelitis in addition to aseptic meningitis include deep muscle pain, hyperesthesias, paresthesias, and, during active myelitis, urinary retention and muscle spasms.[merckmanuals.com]
  • Paralysis of the lower limbs is often accompanied by bowel and bladder dysfunction ranging from transient incontinence to paralysis with constipation and urinary retention. The onset and course of paralysis are variable in developing countries.[easypediatrics.com]
Flaccid Paralysis
  • For this reason, physicians must include poliomyelitis in the differential diagnosis of acute flaccid paralysis in patients who are from these areas.[symptoma.com]
  • The affected muscles are no longer functional and the limb becomes floppy and lifeless – a condition known as acute flaccid paralysis (AFP).[endpolio.com.pk]
  • Asymmetric flaccid paralysis may develop and progress over 2 to 3 days. Encephalitic signs occasionally predominate.[merckmanuals.com]
Cranial Nerve Involvement
  • Cranial nerve involvement Approximately 10-15% of cases affect the lower brainstem motor nuclei. When the ninth and tenth cranial nerve nuclei are involved, patients develop paralysis of pharyngeal and laryngeal musculature.[emedicine.medscape.com]
  • Cranial nerve involvement is seldom permanent. Atrophy of muscles may be evident, patients immobilized for long periods may develop pneumonia, and renal stones may form as a result of hypercalcemia and hypercalciuria secondary to bone resorption.[easypediatrics.com]
Guillain-Barré Syndrome
  • Guillain-Barré syndrome causes flaccid paralysis but can be distinguished because of the following: It usually causes no fever. Muscle weakness is symmetric.[merckmanuals.com]
  • Other causes of acute flaccid paralysis - eg: Various infections Guillain-Barré syndrome Spinal cord lesions Neuropathies Myasthenia gravis Myopathy or myositis Investigations Serology: take acute and convalescent samples.[patient.info]
Dysarthria
  • […] results in extensive damage to the motor neurons of the brainstem which control the respiratory system of the body as a result of which a child affected with Bulbar Polio is likely to experience severe breathing difficulties along with dysphagia and dysarthria[epainassist.com]
  • It can lead to respiratory muscle failure, distress of respiratory control, dysphagia, dysphonia and dysarthria. Cardiovascular, sweating and gut mobility disturbances may occur.[physiotherapy-treatment.com]
Limb Weakness
  • weakness may occur in children, particularly in those whose tonsils and adenoids have been removed.[emedicine.medscape.com]
  • Also, cases of focal limb weakness or paralysis have been identified after infection with enterovirus D68.[merckmanuals.com]

Workup

The diagnosis of poliomyelitis is now rare in the developed world and is restricted to poorly sanitized areas that do not conduct standard vaccination protocols for poliovirus [1] [2]. Countries in which a high risk of an outbreak exists are India, Somalia, Ethiopia, Chad, Congo, Angola and South Sudan, whereas Nigeria, Afghanistan, and Pakistan are considered to be endemic for this virus [1]. For this reason, physicians must include poliomyelitis in the differential diagnosis of acute flaccid paralysis in patients who are from these areas. Apart from assessing information about vaccination, a comprehensive physical examination, especially focusing on neurological evaluation, might provide key findings in order to discriminate bulbar poliomyelitis from other forms of this infection. To solidify the diagnosis, however, microbiological studies need to be conducted. Identification of viral genetic material through a polymerase chain reaction (PCR) test is currently the gold standard of establishing a poliovirus infection [1] [2] [3] [6]. The stool is the ideal sample from which poliovirus can be detected, but blood and throat swab (only in the first few days of infection), as well as the cerebrospinal fluid (CSF), although rare, might be used [1] [2]. Alternatively, serological methods that detect antibodies for this virus might also be implemented, as their very high titers appear early in the course of infection and persist throughout life [1] [2].

Atelectasis
  • During active myelitis, precautions to avoid complications of bed rest (eg, deep venous thrombosis, atelectasis, UTI) and prolonged immobility (eg, contractures) may be necessary. Respiratory failure may require mechanical ventilation.[merckmanuals.com]

Treatment

  • Significant updates on bariatric surgery, Barrett's esophagus, endoscopic ultrasound, endosonography, treatment of liver disease, and much more keep you current on the latest advances.[books.google.com]
  • In addition to summarizing basic science and important technological aspects of diagnosis and treatment, this edition presents new chapters—on sleep and memory consolidation, neuroimaging, and more—in a color layout that makes it easy to access the latest[books.google.com]
  • Also Read: Poliomyelitis: Causes, Symptoms, Treatment Post-Polio Syndrome: Causes, Symptoms, Treatment, Prognosis How Does Poliovirus or Enterovirus Spread, Know its Risk factors & Treatment This article does not provide medical advice.[epainassist.com]
  • Return from Polio treatment to home page Return from Polio treatment to Neuro Rehab[physiotherapy-treatment.com]
  • Treatment: Supportive and symptomatic treatment only. Moist heat, physical therapy and antispasmodic drugs. Positive pressure ventilator or iron lung in bulbar polio. Action: Roll two dice.[web.stanford.edu]

Prognosis

  • THIS report is an analysis primarily of the incidence and prognosis of the various syndromes usually grouped together under the general term "bulbar poliomyelitis."[nejm.org]
  • Also Read: Poliomyelitis: Causes, Symptoms, Treatment Post-Polio Syndrome: Causes, Symptoms, Treatment, Prognosis How Does Poliovirus or Enterovirus Spread, Know its Risk factors & Treatment This article does not provide medical advice.[epainassist.com]
  • Prognosis is generally worse for the older children and in those who had a sudden onset of illness with high fever. Return from Polio treatment to home page Return from Polio treatment to Neuro Rehab[physiotherapy-treatment.com]

Etiology

  • Etiology Causative agent Transmission route Fecal-oral route : absorption of poliovirus in the intestinal tract Rarely, droplet transmission may occur during epidemics.[amboss.com]
  • Ongoing controversies regarding etiology, diagnosis, treatment During 2000 and 2001, an outbreak of 21 cases of paralytic poliomyelitis on the island of Hispaniola occurred, caused by a virulent strain genetically related to the type 1 Sabin OPV vaccine[clinicaladvisor.com]

Epidemiology

  • The evolution of poliomyelitis to global epidemiological significance from the 1920s marks it out as one of the world's major emergent infections of the twentieth century.[books.google.de]
  • Epidemiology of Infectious Diseases: Poliomyelitis Causal agent Poliovirus (genus Enterovirus ), types 1, 2 and 3. Type 1 is commonly associated with paralytic poliomyelitis and epidemics 1.[healthknowledge.org.uk]
  • Epidemiology Due to widespread vaccination measures, poliomyelitis has been eradicated from the United States and most other countries. Poliovirus is still endemic in Afghanistan, Nigeria, and Pakistan.[amboss.com]
  • Data on poliomyelitis surveillance and disease incidence are reported in ECDC’s Annual Epidemiological Report on Communicable Diseases in Europe available here.[ecdc.europa.eu]
  • “From Emergence to eradication: the epidemiology of poliomyelitis deconstructed”. Am J Epidemiol. vol. 172. 2010. pp. 1213-1229.[clinicaladvisor.com]
Sex distribution
Age distribution

Pathophysiology

  • Incubation time Pathophysiology The virus replicates in the gastrointestinal tract following oral ingestion enters the bloodstream potential invasion of the grey matter of the spinal cord ( particularly the anterior horn cells ) Clinical features Over[amboss.com]
  • A girl with deformity in right lower limb after polio, non copyrighted image from Wikipedia Pathophysiology of Polio Poliovirus is a type of enterovirus, a group of RNA viruses that colonize the gastrointestinal tract.[medcaretips.com]

Prevention

  • The electrophrenic respirator was instrumental in maintaining this patient's respiration and massive blood transfusions in preventing shock from intestinal hemorrhage.[pediatrics.aappublications.org]
  • But, from the 1950s, this picture abruptly changed when preventive vaccines were developed which have brought the disease to the edge of global eradication.[books.google.de]
  • Centers for Disease Control and Prevention Polio: Information for Parents (American Academy of Family Physicians) Polio: Information for Parents (American Academy of Pediatrics) Polio: Information for Parents (Centers for Disease Control and Prevention[icdlist.com]
  • Polio and prevention Polio is a crippling and potentially fatal infectious disease. There is no cure, but there are safe and effective vaccines.[endpolio.com.pk]
  • Polio can be prevented through immunization. Polio vaccine, given multiple times, almost always protects a child for life.[polioplusng.org]

References

Article

  1. Mehndiratta MM, Mehndiratta P, Pande R. Poliomyelitis: Historical Facts, Epidemiology, and Current Challenges in Eradication. Lyons J, ed. Neurohospitalist. 2014;4(4):223-229.
  2. Melnick JL. Current status of poliovirus infections. Clin Microbiol Rev. 1996;9(3):293–300.
  3. Howard RS. Poliomyelitis and the postpolio syndrome. BMJ. 2005;330(7503):1314-1318.
  4. Kilpatrick DR, Nottay B, Yang CF, et al. Group specific identification of poliovirus by PCR using primers containing mixed-base or deoxyinosine residues at positions of codon degeneracy. J Clin Microbiol. 1996;34: 2990-2996.
  5. Baicus A. History of polio vaccination. World Journal of Virology. 2012;1(4):108-114.
  6. Porter RS, Kaplan JL. Merck Manual of Diagnosis and Therapy. 19th Edition. Merck Sharp & Dohme Corp. Whitehouse Station, N.J; 2011.

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Last updated: 2018-06-22 02:24