Polio natural history, complications and prognosis: Difference between revisions

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==Overview==
==Overview==
Many cases of poliomyelitis result in only temporary [[paralysis]].  After an interval of 30–40 years, 25%–40% of persons who contracted paralytic poliomyelitis in childhood experience new muscle pain and exacerbation of existing weakness, or develop new weakness or paralysis. This disease entity is referred to as pos-tpolio syndrome.  Patients with abortive polio infections recover completely. In those that develop only [[aseptic meningitis]], the symptoms can be expected to persist for two to ten days, followed by complete recovery.
Poliovirus initially colonizes the cells of the [[gastrointestinal]] tract.  When [[symptoms]] occur, these usually follow an [[incubation period]] of 7 to 14 days.  The disease may manifest as ''abortive poliomyelitis'', lasting for 2-3 days with nonspecific [[symptoms]] of fatigue, nausea, and sore throat, ''non-paralytic poliomyelitis'', lasting about 2-10 days which with signs of meningeal irritation, and ''paralytic poliomyelitis'' with [[symptoms]] such as [[hyperesthesia]], [[paresthesia]], and [[paralysis]]. [[Complications]] of poliomyelitis may include [[respiratory]] compromise, [[gastrointestinal]] symptoms, [[musculoskeletal]] deformities, and post-poliomyelitis syndrome.  The [[prognosis]] of poliomyelitis depends on the form of the disease: patients with abortive poliomyelitis often have a full recovery; while patients with severe form of disease have poorer outcome. [[Paralysis]] of the [[respiratory]] muscles is a sign of bad [[prognosis]] and these patients have higher mortality.


==Natural History==
==Natural History==
<!--
[[Poliovirus]] enters the body through the oral cavity, infecting nearby cells, such as those of the [[oral mucosa]], nose and throat.  The [[incubation period]] often ranges from 7 to 14 days, however,  it may vary from 5 to 35 days.<ref name="pmid15885840">{{cite journal| author=Mueller S, Wimmer E, Cello J| title=Poliovirus and poliomyelitis: a tale of guts, brains, and an accidental event. | journal=Virus Res | year= 2005 | volume= 111 | issue= 2 | pages= 175-93 | pmid=15885840 | doi=10.1016/j.virusres.2005.04.008 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15885840  }} </ref><ref name="mend">{{cite book | last = Mandell | first = Gerald | title = Mandell, Douglas, and Bennett's principles and practice of infectious diseases | publisher = Churchill Livingstone/Elsevier | location = Philadelphia, PA | year = 2010 | isbn = 0443068399 }}</ref>
The incubation period ranges from 7 to 14 days but may vary from 2 to 35 days. Although the precise sites and cell types involved in the primary replication of poliovirus in the gastrointestinal tract are not known, virus could generally be isolated from the lymphatic tissues of the gastrointestinal tract, such as the tonsils, the Peyer’s patches of the ileum and mesenteric lymph nodes (Bodian, 1956b; Sabin and Ward, 1941; Bodian and Horstmann, 1965; Melnick, 1996; Sabin, 1956). Primary (minor) transient viremia occurs in most infected individuals and the virus spreads to the systemic reticuloendothelial tissue without clinical manifestations. In 4–8% of the infected individuals, a second major viremia ensues causing symptoms of “minor illness” (headache, sore throat, fever) (Bodian and Horstmann, 1965; Melnick, 1996; Sabin, 1956). A fraction of those with major viremia proceed to develop symptoms of CNS involvement. Thus, neurological symptoms are rare complications of the PV infection and poliomyelitis (the most important and devastating disease causes by PV) affects less than 1% of PV infected individuals (Nathanson and Martin, 1979). Poliomyelitis can therefore be regarded as an “accident” of the enteric infection, that is neither an obligatory stage of PV replication nor of any known benefit to the virus. The molecular mechanisms by which PV causes poliomyelitis are poorly understood. This is remarkable considering that PV is one of the most thoroughly investigated viruses of all times. Our knowledge of PV pathogenesis is based mainly on experiments in primate and mouse models


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Typical manifestations of poliomyelitis may range from [[asymptomatic]] disease, to death. 95% of infections with poliovirus are [[asymptomatic]].  4 to 8% of the cases present as abortive poliomyelitis. In about 1 to 2% of infections, the disease manifests as non-paralytic poliomyelitis. Less than 1% of infected patients develop [[paralytic]] disease.
Many cases of poliomyelitis result in only temporary paralysis.<ref>Frauenthal HWA, Manning JVV (1914). Manual of infantile paralysis, with modern methods of treatment.. Philadelphia Davis, 79–101. OCLC 2078290</ref> Nerve impulses return to the formerly paralyzed muscle within a month, and recovery is usually complete in six to eight months. The [[neurophysiology|neurophysiological]] processes involved in recovery following acute paralytic poliomyelitis are quite effective; muscles are able to retain normal strength even if half the original motor neurons have been lost.<ref>{{cite journal |author=Sandberg A, Hansson B, Stålberg E |title=Comparison between concentric needle EMG and macro EMG in patients with a history of polio |journal=Clinical Neurophysiology |volume=110 |issue=11 |pages=1900–8 |year=1999 |pmid=10576485}}</ref> Paralysis remaining after one year is likely to be permanent, although modest recoveries of muscle strength are possible 12 to 18 months after infection.


One mechanism involved in recovery is nerve terminal sprouting, in which remaining [[brainstem]] and [[spinal cord]] motor neurons develop new branches, or ''axonal sprouts''.<ref>{{cite journal |author=Cashman NR, Covault J, Wollman RL, Sanes JR |title=Neural cell adhesion molecule in normal, denervated, and myopathic human muscle |journal=Ann. Neurol. |volume=21 |issue=5 |pages=481–9 |year=1987 |pmid=3296947}}</ref> These sprouts can [[reinnervate]] orphaned muscle fibers that have been denervated by acute polio infection,<ref name=Agre>{{cite journal |author=Agre JC, Rodríquez AA, Tafel JA |title=Late effects of polio: critical review of the literature on neuromuscular function |journal=Archives of physical medicine and rehabilitation |volume=72 |issue=11 |pages=923–31 |year=1991 |pmid=1929813}}</ref> restoring the fibers' capacity to contract and improving strength.<ref>{{cite journal |author=Trojan DA, Cashman NR |title=Post-poliomyelitis syndrome |journal=Muscle Nerve |volume=31 |issue=1 |pages=6–19 |year=2005 |pmid=15599928}}</ref> Terminal sprouting may generate a few significantly enlarged motor neurons doing work previously performed by as many as four or five units: <ref>Gawne AC, Halstead LS (1995). "Post-polio syndrome: pathophysiology and clinical management". Critical Review in Physical Medicine and Rehabilitation 7: 147–88. Reproduced online with permission by Lincolnshire Post-Polio Library; retrieved on 2007-11-10.</ref> a single motor neuron that once controlled 200 muscle cells might control 800 to 1000 cells. Other mechanisms that occur during the rehabilitation phase, and contribute to muscle strength restoration, include [[muscle hypertrophy|myofiber hypertrophy]]&mdash;enlargement of muscle fibers through exercise and activity&mdash;and transformation of [[Muscle fiber#Type II|type II muscle fibers]] to [[Muscle fiber#Type I| type I muscle fibers]].<ref name=Agre /><ref name = Grimby_1989>{{cite journal |author=Grimby G, Einarsson G, Hedberg M, Aniansson A |title=Muscle adaptive changes in post-polio subjects |journal=Scandinavian journal of rehabilitation medicine |volume=21 |issue=1 |pages=19–26 |year=1989 |pmid=2711135}}</ref>  
===Abortive Poliomyelitis===
Abortive poliomyelitis often presents with 2 to 3 days of [[fever]].  [[Neurological exam]] is normal in this form of the disease, and common [[symptoms]] may include [[sore throat]], [[headache]], [[anorexia]], [[nausea]], [[vomiting]], and [[abdominal pain]].<ref name="mend">{{cite book | last = Mandell | first = Gerald | title = Mandell, Douglas, and Bennett's principles and practice of infectious diseases | publisher = Churchill Livingstone/Elsevier | location = Philadelphia, PA | year = 2010 | isbn = 0443068399 }}</ref>
===Non-Paralytic Poliomyelitis===
This form of the disease presents with symptoms of abortive poliomyelitis; however, these are often more severe, and signs of [[meningeal]] irritation are present.<ref name="mend">{{cite book | last = Mandell | first = Gerald | title = Mandell, Douglas, and Bennett's principles and practice of infectious diseases | publisher = Churchill Livingstone/Elsevier | location = Philadelphia, PA | year = 2010 | isbn = 0443068399 }}</ref>  Typically [[symptoms]] in non-paralytic polio last for 2 to 10 days, and patients are expected to achieve complete recovery.<ref name=CDC>{{cite web | title = Poliomyelitis | url = http://www.cdc.gov/vaccines/pubs/pinkbook/downloads/polio.pdf }}</ref>


In addition to these physiological processes, the body possesses a number of compensatory mechanisms to maintain function in the presence of residual paralysis. These include the use of weaker muscles at a higher than usual intensity relative to the [[Muscle contraction#Contractions, by muscle type|muscle's maximal capacity]], enhancing athletic development of previously little-used muscles, and using [[ligament]]s for stability, which enables greater mobility.
===Paralytic Poliomyelitis===
Paralytic symptoms generally begin 1 to 10 days after [[prodromal]] symptoms, and evolve during 2 to 3 days. The [[prodrome]] may be biphasic, especially in children, with initial minor [[symptoms]] separated from major symptoms, by 1 to 7 days.  Adults commonly present with a single phase of [[symptoms]], with prolongation of the [[prodrome]] until onset of [[paralysis]].<ref name=CDC>{{cite web | title = Poliomyelitis | url = http://www.cdc.gov/vaccines/pubs/pinkbook/downloads/polio.pdf }}</ref><ref name="mend">{{cite book | last = Mandell | first = Gerald | title = Mandell, Douglas, and Bennett's principles and practice of infectious diseases | publisher = Churchill Livingstone/Elsevier | location = Philadelphia, PA | year = 2010 | isbn = 0443068399 }}</ref><ref name="pmid18126001">{{cite journal| author=HORSTMANN DM| title=Clinical aspects of acute poliomyelitis. | journal=Am J Med | year= 1949 | volume= 6 | issue= 5 | pages= 592-605 | pmid=18126001 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18126001  }} </ref>
====Spinal Paralytic Poliomyelitis====
Severe paralysis occurs in about 0.1% of the cases.  Initial minor symptoms are similar to those of abortive poliomyelitis, lasting 1 to 3 days.  After this initial period, the patient recovers over 2 to 5 days, until severe symptoms develop.  The severe phase of this form of poliomyelitis is characterized by signs and symptoms of [[aseptic meningitis]]. These include [[fever]], [[chills]], [[nausea]], [[vomiting]], [[photophobia]], and [[neck stiffness]].<ref name="mend">{{cite book | last = Mandell | first = Gerald | title = Mandell, Douglas, and Bennett's principles and practice of infectious diseases | publisher = Churchill Livingstone/Elsevier | location = Philadelphia, PA | year = 2010 | isbn = 0443068399 }}</ref>
 
The more severe phase begins with [[hyperesthesia]], [[paresthesia]], [[myalgia]], and [[muscle spasms]].  [[Meningeal]] symptoms start 2 days before the onset of [[paralysis]].  [[Muscular]] symptoms are often asymmetrical and may vary from mild weakness to quadriplegia.  Lower limbs tend to be more affected than the upper limbs, and symptoms may occur in different combinations of limbs.  [[Paralysis]] usually lasts 2 to 3 days, and its progression stops when [[fever]] decreases. Twenty five percent of adults also experience [[bladder]] muscle paralysis.<ref name="mend">{{cite book | last = Mandell | first = Gerald | title = Mandell, Douglas, and Bennett's principles and practice of infectious diseases | publisher = Churchill Livingstone/Elsevier | location = Philadelphia, PA | year = 2010 | isbn = 0443068399 }}</ref>
 
====Bulbar Paralytic Poliomyelitis====
Patients with bulbar paralytic poliomyelitis often experience difficulty swallowing and breathing.  This form occurs in about 5-35% of the cases where paralysis occurs.  The most common sign is accumulation of [[pharyngeal]] secretions.<ref name="pmid18126002">{{cite journal| author=BAKER AB| title=Bulbar poliomyelitis; its mechanism and treatment. | journal=Am J Med | year= 1949 | volume= 6 | issue= 5 | pages= 614-9 | pmid=18126002 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18126002  }} </ref>
 
====Polioencephalitis====
Occurrence of [[encephalitis]] in a patient with poliomyelitis is uncommon and occurs more frequently in infants.  [[Confusion]] is commonly the first [[symptom]] of polioencephalitis.  It may also be accompanied by [[spastic]] [[paralysis]] and [[seizures]].<ref name="mend">{{cite book | last = Mandell | first = Gerald | title = Mandell, Douglas, and Bennett's principles and practice of infectious diseases | publisher = Churchill Livingstone/Elsevier | location = Philadelphia, PA | year = 2010 | isbn = 0443068399 }}</ref>


== Complications==
== Complications==
Potential [[complications]] of poliomyelitis may include:<ref>{{cite book | last = Mandell | first = Gerald | title = Mandell, Douglas, and Bennett's principles and practice of infectious diseases | publisher = Churchill Livingstone/Elsevier | location = Philadelphia, PA | year = 2010 | isbn = 0443068399 }}</ref><ref name="pmid13427128">{{cite journal| author=WEINSTEIN L| title=Cardiovascular disturbances in poliomyelitis. | journal=Circulation | year= 1957 | volume= 15 | issue= 5 | pages= 735-56 | pmid=13427128 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=13427128  }} </ref><ref name="pmid13826196">{{cite journal| author=GALPINE JF, WILSON WC| title=Occurrence of myocarditis in paralytic poliomyelitis. | journal=Br Med J | year= 1959 | volume= 2 | issue= 5163 | pages= 1379-81 | pmid=13826196 | doi= | pmc=PMC1990933 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=13826196  }} </ref><ref name=MayoComps>{{cite web |author = Mayo Clinic Staff | date=[[2005-05-19]] | url = http://www.mayoclinic.com/health/polio/DS00572/DSECTION=7  | title = Polio: Complications| publisher = Mayo Foundation for Medical Education and Research (MFMER)| accessdate=2007-02-26}}</ref>
Potential [[complications]] of poliomyelitis may include:<ref name="mend">{{cite book | last = Mandell | first = Gerald | title = Mandell, Douglas, and Bennett's principles and practice of infectious diseases | publisher = Churchill Livingstone/Elsevier | location = Philadelphia, PA | year = 2010 | isbn = 0443068399 }}</ref><ref name="pmid13427128">{{cite journal| author=WEINSTEIN L| title=Cardiovascular disturbances in poliomyelitis. | journal=Circulation | year= 1957 | volume= 15 | issue= 5 | pages= 735-56 | pmid=13427128 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=13427128  }} </ref><ref name="pmid13826196">{{cite journal| author=GALPINE JF, WILSON WC| title=Occurrence of myocarditis in paralytic poliomyelitis. | journal=Br Med J | year= 1959 | volume= 2 | issue= 5163 | pages= 1379-81 | pmid=13826196 | doi= | pmc=PMC1990933 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=13826196  }} </ref><ref name=MayoComps>{{cite web |author = Mayo Clinic Staff | date=[[2005-05-19]] | url = http://www.mayoclinic.com/health/polio/DS00572/DSECTION=7  | title = Polio: Complications| publisher = Mayo Foundation for Medical Education and Research (MFMER)| accessdate=2007-02-26}}</ref><ref name="pmid1442743">{{cite journal| author=Ramlow J, Alexander M, LaPorte R, Kaufmann C, Kuller L| title=Epidemiology of the post-polio syndrome. | journal=Am J Epidemiol | year= 1992 | volume= 136 | issue= 7 | pages= 769-86 | pmid=1442743 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1442743  }} </ref><ref name="pmid6330854">{{cite journal| author=Dalakas MC, Sever JL, Madden DL, Papadopoulos NM, Shekarchi IC, Albrecht P et al.| title=Late postpoliomyelitis muscular atrophy: clinical, virologic, and immunologic studies. | journal=Rev Infect Dis | year= 1984 | volume= 6 Suppl 2 | issue=  | pages= S562-7 | pmid=6330854 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=6330854  }} </ref><ref name="pmid3007983">{{cite journal| author=Dalakas MC, Elder G, Hallett M, Ravits J, Baker M, Papadopoulos N et al.| title=A long-term follow-up study of patients with post-poliomyelitis neuromuscular symptoms. | journal=N Engl J Med | year= 1986 | volume= 314 | issue= 15 | pages= 959-63 | pmid=3007983 | doi=10.1056/NEJM198604103141505 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3007983  }} </ref><ref name="pmid6330855">{{cite journal| author=Johnson RT| title=Late progression of poliomyelitis paralysis: discussion of pathogenesis. | journal=Rev Infect Dis | year= 1984 | volume= 6 Suppl 2 | issue=  | pages= S568-70 | pmid=6330855 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=6330855  }} </ref>


{| style="border: 0px; font-size: 90%; margin: 3px;" align=center
{| style="border: 0px; font-size: 90%; margin: 3px;" align=center
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! style="background: #4479BA; width: 500px;" | {{fontcolor|#FFF|Description}}
! style="background: #4479BA; width: 500px;" | {{fontcolor|#FFF|Description}}
|-
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''Respiratory compromise'''
| style="padding: 5px 5px; background: #DCDCDC;" | '''Respiratory'''
| style="padding: 5px 5px; background: #F5F5F5;" |
| style="padding: 5px 5px; background: #F5F5F5;" |
* Resulting from paralysis of respiratory muscles (diaphragm and intercostal muscles)
* Respiratory compromise resulting from paralysis of [[respiratory]] muscles (diaphragm and intercostal muscles)
* Airway obstruction
* [[Airway obstruction]]
* Lesions in:
* Occurs due to lesions in the [[cranial nerve nuclei]] and [[medulla]]
:* Cranial nerve nuclei
:* Medullary respiratory center
|-
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''Myocarditis'''
| style="padding: 5px 5px; background: #DCDCDC;" | '''Cardiac'''
| style="padding: 5px 5px; background: #F5F5F5;" |
| style="padding: 5px 5px; background: #F5F5F5;" |
* Inflammatory infiltration in cardiac muscle
* Myocarditis
|-
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''Gastrointestinal'''
| style="padding: 5px 5px; background: #DCDCDC;" | '''Gastrointestinal'''
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* [[Hemorrhage]]
* [[Hemorrhage]]
* [[Paralytic ileus]]
* [[Paralytic ileus]]
* [[Gastric dilatation]]
* [[Gastric]] dilatation
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''Musculoskeletal'''
| style="padding: 5px 5px; background: #F5F5F5;" |
* Permanent [[muscle]] paralysis
* [[Skeletal]] deformities:
:* [[Hip]]s
:* [[Ankle]]s
:* [[Feet]]
|-
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''Musculo-Skeletal'''
| style="padding: 5px 5px; background: #DCDCDC;" | '''Postpoliomyelitis Syndrome'''
| style="padding: 5px 5px; background: #F5F5F5;" |
| style="padding: 5px 5px; background: #F5F5F5;" |
* Permanent muscle paralysis
* Occurs in 20-30% of patients with history of paralytic poliomyelitis (25-35 years before), who have made a partial or full recovery
* Skeletal deformities:
* Commonly involves previously affected muscles
:* Hips
* Possible cause is attrition of motor nerves that innervate previously affected muscles
:* Ankles
* New onset of:
:* Feet
:*[[Fatigue]]
:*[[Myalgia]]
:*[[Muscle weakness]]
:*[[Muscle atrophy]]
* Gradual symptom progression
|-
|-
|}
|}
===Post-polio syndrome===
<!--
Postpoliomyelitis Syndrome (Mandel)
Some patients who partially or fully recover from paralytic poliomy- elitis experience a new onset of muscle weakness, pain, atrophy, and fatigue many years after the acute illness.56 Typically, the involved muscles are the same as those affected during the original illness, but weakness may also occur in previously unaffected limb muscles. Pro- gression of new symptoms is gradual and affected persons are seldom severely disabled.57 Population-based studies suggest that the syn- drome affects 20% to 30% of previously paralyzed patients.58 The risk of postpoliomyelitis syndrome peaks between 25 and 35 years after acute poliomyelitis.58 Although the cause is unknown, some authori- ties believe that late progression of muscle weakness is a result of physiologic attrition of motor units innervating muscles and muscle groups already less innervated as a result of earlier acute poliomyelitis.59
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Around a quarter of individuals who survive paralytic polio in childhood develop additional symptoms decades after recovering from the acute infection, notably [[muscle weakness]], extreme [[fatigue]], or [[paralysis]]. This condition is known as [[post-polio syndrome]] (PPS).<ref name=Cashman>{{cite journal |author=Trojan D, Cashman N |title=Post-poliomyelitis syndrome |journal=Muscle Nerve |volume=31 |issue=1 |pages=6–19 |year=2005 |pmid = 15599928}}</ref> The symptoms of PPS are thought to involve a failure of the over-sized motor units created during recovery from paralytic disease.<ref name=Ramlow_1992>{{cite journal |author=Ramlow J, Alexander M, LaPorte R, Kaufmann C, Kuller L |title=Epidemiology of the post-polio syndrome |journal=Am. J. Epidemiol. |volume=136 |issue=7 |pages=769–86 |year=1992 |pmid=1442743}}</ref><ref name= Annals>{{cite journal |author=Lin K, Lim Y |title=Post-poliomyelitis syndrome: case report and review of the literature| url= http://www.annals.edu.sg/pdf/34VolNo7200508/V34N7p447.pdf | format = PDF |journal=Ann Acad Med Singapore |volume=34 |issue=7 |pages=447–9 |year=2005 |pmid = 16123820}}</ref> Factors that increase the risk of PPS include the length of time since acute poliovirus infection, the presence of permanent residual impairment after recovery from the acute illness, and both overuse and disuse of neurons. Post-polio syndrome is not an infectious process, and persons experiencing the syndrome do not shed poliovirus.


==Prognosis==
==Prognosis==
<!--
* The [[mortality rate]] from acute paralytic poliomyelitis during its [[epidemic]] stage was approximately 5-10% of symptomatic individuals; higher  mortality was noted in cases of bulbar poliomyelitis.<ref name="pmid13822503">{{cite journal| author=FERRIS BG, AULD PA, CRONKHITE L, KAUFMANN HJ, KEARSLEY RB, PRIZER M et al.| title=Life-threatening poliomyelitis, Boston, 1955. | journal=N Engl J Med | year= 1960 | volume= 262 | issue=  | pages= 371-80 | pmid=13822503 | doi=10.1056/NEJM196002252620801 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=13822503  }} </ref>
(Mandel)
* Patients with abortive poliomyelitis often have a full recovery.<ref name="mend">{{cite book | last = Mandell | first = Gerald | title = Mandell, Douglas, and Bennett's principles and practice of infectious diseases | publisher = Churchill Livingstone/Elsevier | location = Philadelphia, PA | year = 2010 | isbn = 0443068399 }}</ref>
Muscular paralysis usually progresses or extends for only 1 to 3 days after its onset, but occasionally for as long as 1 week.52 Permanent weakness is observed in approximately two thirds of patients with paralytic poliomyelitis. Complete recovery is less likely when acute paralysis is severe and when patients require mechanical ventilation. An estimate of the eventual outcome can be made after 1 month, when most reversible damage has disappeared. Very little additional return of function can be expected beyond 9 months. Recovery from pharyn- geal paralysis usually is evident by 10 days and is eventually complete. Bulbar poliomyelitis is rarely responsible for permanent sequelae in surviving patients.
* Patients who develop [[aseptic meningitis]] can have [[symptoms]] for 2-10 days and often recover fully.<ref name=Neumann>{{cite journal |author=Neumann D |title=Polio: its impact on the people of the United States and the emerging profession of physical therapy |url= http://www.post-polio.org/edu/hpros/Aug04HistPersNeumann.pdf | format = PDF | journal=The Journal of orthopaedic and sports physical therapy |volume=34 |issue=8 |pages=479–92 |year=2004 |pmid=15373011}} Reproduced online with permission by Post-Polio Health International; retrieved on [[2007-11-10]].</ref>
 
* In paralytic  poliomyelitis, [[muscle]] [[paralysis]] usually lasts 1-3 days, and in some cases up to 1 week.<ref name="Ritchie RussellFischer-Williams1954">{{cite journal|last1=Ritchie Russell|first1=W.|last2=Fischer-Williams|first2=M.|title=RECOVERY OF MUSCULAR STRENGTH AFTER POLIOMYELITIS|journal=The Lancet|volume=263|issue=6807|year=1954|pages=330–333|issn=01406736|doi=10.1016/S0140-6736(54)91084-3}}</ref> Persistent weakness occurs in two thirds of patients.  
Available mortality figures date from the era of epidemic poliomy- elitis, a period when critical care medicine was less advanced than it is today. The reported overall mortality for acute paralytic poliomyelitis during this period was 5% to 10%, but was substantially higher with bulbar involvement.53
* Patients with severe form of paralytic poliomyelitis, and those who require [[mechanical ventilation]] have lower probability of achieving recovery.<ref name="mend">{{cite book | last = Mandell | first = Gerald | title = Mandell, Douglas, and Bennett's principles and practice of infectious diseases | publisher = Churchill Livingstone/Elsevier | location = Philadelphia, PA | year = 2010 | isbn = 0443068399 }}</ref>
 
* 5- 10% of patients with paralytic poliomyelitis die of[[respiratory]] [[muscles]] paralysis. The [[mortality rate]] varies with age: 2-5% in children, 15-30% in adults.  
-->
* In the absence of support, bulbar poliomyelitis has a [[mortality rate]] of 25-75%, depending on the patient's age.<ref>{{cite journal |author=Miller AH, Buck LS |title=Tracheotomy in bulbar poliomyelitis |url= http://www.pubmedcentral.nih.gov/pagerender.fcgi?artid=1520308&pageindex=1#page |journal=California medicine |volume=72 |issue=1 |pages=34–6 |year=1950 |pmid=15398892 |doi=}}</ref> With adequate positive pressure [[ventilation]], the [[mortality]] can be reduced to 15%.<ref name=Wackers>{{cite paper| author = Wackers, G.| title = Constructivist Medicine| version = PhD-thesis| publisher = Maastricht: Universitaire Pers Maastricht| date = 1994| url = http://www.fdcw.unimaas.nl/personal/WebSitesMWT/Wackers/proefschrift.html#h4| format = [[web]]| accessdate = 2008-01-04 }}</ref>
 
* Permanent sequelae are uncommon in patients who have survived bulbar poliomyelitis.<ref name="mend">{{cite book | last = Mandell | first = Gerald | title = Mandell, Douglas, and Bennett's principles and practice of infectious diseases | publisher = Churchill Livingstone/Elsevier | location = Philadelphia, PA | year = 2010 | isbn = 0443068399 }}</ref>
Patients with abortive polio infections recover completely. In those that develop only aseptic meningitis, the symptoms can be expected to persist for two to ten days, followed by complete recovery. In cases of spinal polio, if the affected nerve cells are completely destroyed, paralysis will be permanent; cells that are not destroyed but lose function temporarily may recover within four to six weeks after onset.<ref name=Neumann>{{cite journal |author=Neumann D |title=Polio: its impact on the people of the United States and the emerging profession of physical therapy |url= http://www.post-polio.org/edu/hpros/Aug04HistPersNeumann.pdf | format = PDF | journal=The Journal of orthopaedic and sports physical therapy |volume=34 |issue=8 |pages=479–92 |year=2004 |pmid=15373011}} Reproduced online with permission by Post-Polio Health International; retrieved on [[2007-11-10]].</ref> Half the patients with spinal polio recover fully, one quarter recover with mild disability and the remaining quarter are left with severe disability.<ref>{{cite book |author=Cuccurullo SJ |title=Physical Medicine and Rehabilitation Board Review |url= http://www.ncbi.nlm.nih.gov/books/bv.fcgi?&rid=physmedrehab.table.8357 | publisher=Demos Medical Publishing | year = 2004  |isbn=1-888799-45-5}}</ref> The degree of both acute paralysis and residual paralysis is likely to be proportional to the degree of [[viremia]], and inversely proportional to the degree of [[immunity (medical)|immunity]].<ref>Mueller S, Wimmer E, Cello J (2005). "Poliovirus and poliomyelitis: a tale of guts, brains, and an accidental event". Virus Res 111 (2): 175–93. PMID 15885840</ref>. Spinal polio is rarely fatal.<ref>Silverstein A, Silverstein V, Nunn LS (2001). Polio, Diseases and People. Berkeley Heights, NJ: Enslow Publishers, 12. ISBN 0-7660-1592-0.</ref>
 
[[Image:Polio sequelle.jpg|thumb|center|A child with a deformity of her right leg due to polio]]
 
Without respiratory support, consequences of poliomyelitis with [[Respiration (physiology)|respiratory]] involvement include [[suffocation]] or [[aspiration pneumonia|pneumonia from aspiration of secretions]].<ref name= Goldberg>{{cite journal |author=Goldberg A |title=Noninvasive mechanical ventilation at home: building upon the tradition |url= http://www.chestjournal.org/cgi/content/full/121/2/321 |journal=[[Chest (journal)|Chest]] |volume=121 |issue=2 |pages=321–4 |year=2002 |id=PMID 11834636}}</ref> Overall, 5–10% of patients with paralytic polio die due to the paralysis of muscles used for breathing. The mortality rate varies by age: 2–5% of children and up to 15–30% of adults die. Bulbar polio often causes death if respiratory support is not provided;<ref name= Hoyt /> with support, its mortality rate ranges from 25 to 75%, depending on the age of the patient.<ref>{{cite journal |author=Miller AH, Buck LS |title=Tracheotomy in bulbar poliomyelitis |url= http://www.pubmedcentral.nih.gov/pagerender.fcgi?artid=1520308&pageindex=1#page |journal=California medicine |volume=72 |issue=1 |pages=34–6 |year=1950 |pmid=15398892 |doi=}}</ref> When positive pressure ventilators are available, the mortality can be reduced to 15%.<ref name=Wackers>{{cite paper| author = Wackers, G.| title = Constructivist Medicine| version = PhD-thesis| publisher = Maastricht: Universitaire Pers Maastricht| date = 1994| url = http://www.fdcw.unimaas.nl/personal/WebSitesMWT/Wackers/proefschrift.html#h4| format = [[web]]| accessdate = 2008-01-04 }}</ref>


==References==
==References==
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: João André Alves Silva, M.D. [2]

Overview

Poliovirus initially colonizes the cells of the gastrointestinal tract. When symptoms occur, these usually follow an incubation period of 7 to 14 days. The disease may manifest as abortive poliomyelitis, lasting for 2-3 days with nonspecific symptoms of fatigue, nausea, and sore throat, non-paralytic poliomyelitis, lasting about 2-10 days which with signs of meningeal irritation, and paralytic poliomyelitis with symptoms such as hyperesthesia, paresthesia, and paralysis. Complications of poliomyelitis may include respiratory compromise, gastrointestinal symptoms, musculoskeletal deformities, and post-poliomyelitis syndrome. The prognosis of poliomyelitis depends on the form of the disease: patients with abortive poliomyelitis often have a full recovery; while patients with severe form of disease have poorer outcome. Paralysis of the respiratory muscles is a sign of bad prognosis and these patients have higher mortality.

Natural History

Poliovirus enters the body through the oral cavity, infecting nearby cells, such as those of the oral mucosa, nose and throat. The incubation period often ranges from 7 to 14 days, however, it may vary from 5 to 35 days.[1][2]

Typical manifestations of poliomyelitis may range from asymptomatic disease, to death. 95% of infections with poliovirus are asymptomatic. 4 to 8% of the cases present as abortive poliomyelitis. In about 1 to 2% of infections, the disease manifests as non-paralytic poliomyelitis. Less than 1% of infected patients develop paralytic disease.

Abortive Poliomyelitis

Abortive poliomyelitis often presents with 2 to 3 days of fever. Neurological exam is normal in this form of the disease, and common symptoms may include sore throat, headache, anorexia, nausea, vomiting, and abdominal pain.[2]

Non-Paralytic Poliomyelitis

This form of the disease presents with symptoms of abortive poliomyelitis; however, these are often more severe, and signs of meningeal irritation are present.[2] Typically symptoms in non-paralytic polio last for 2 to 10 days, and patients are expected to achieve complete recovery.[3]

Paralytic Poliomyelitis

Paralytic symptoms generally begin 1 to 10 days after prodromal symptoms, and evolve during 2 to 3 days. The prodrome may be biphasic, especially in children, with initial minor symptoms separated from major symptoms, by 1 to 7 days. Adults commonly present with a single phase of symptoms, with prolongation of the prodrome until onset of paralysis.[3][2][4]

Spinal Paralytic Poliomyelitis

Severe paralysis occurs in about 0.1% of the cases. Initial minor symptoms are similar to those of abortive poliomyelitis, lasting 1 to 3 days. After this initial period, the patient recovers over 2 to 5 days, until severe symptoms develop. The severe phase of this form of poliomyelitis is characterized by signs and symptoms of aseptic meningitis. These include fever, chills, nausea, vomiting, photophobia, and neck stiffness.[2]

The more severe phase begins with hyperesthesia, paresthesia, myalgia, and muscle spasms. Meningeal symptoms start 2 days before the onset of paralysis. Muscular symptoms are often asymmetrical and may vary from mild weakness to quadriplegia. Lower limbs tend to be more affected than the upper limbs, and symptoms may occur in different combinations of limbs. Paralysis usually lasts 2 to 3 days, and its progression stops when fever decreases. Twenty five percent of adults also experience bladder muscle paralysis.[2]

Bulbar Paralytic Poliomyelitis

Patients with bulbar paralytic poliomyelitis often experience difficulty swallowing and breathing. This form occurs in about 5-35% of the cases where paralysis occurs. The most common sign is accumulation of pharyngeal secretions.[5]

Polioencephalitis

Occurrence of encephalitis in a patient with poliomyelitis is uncommon and occurs more frequently in infants. Confusion is commonly the first symptom of polioencephalitis. It may also be accompanied by spastic paralysis and seizures.[2]

Complications

Potential complications of poliomyelitis may include:[2][6][7][8][9][10][11][12]

Complications Description
Respiratory
Cardiac
  • Myocarditis
Gastrointestinal
Musculoskeletal
Postpoliomyelitis Syndrome
  • Occurs in 20-30% of patients with history of paralytic poliomyelitis (25-35 years before), who have made a partial or full recovery
  • Commonly involves previously affected muscles
  • Possible cause is attrition of motor nerves that innervate previously affected muscles
  • New onset of:
  • Gradual symptom progression

Prognosis

  • The mortality rate from acute paralytic poliomyelitis during its epidemic stage was approximately 5-10% of symptomatic individuals; higher mortality was noted in cases of bulbar poliomyelitis.[13]
  • Patients with abortive poliomyelitis often have a full recovery.[2]
  • Patients who develop aseptic meningitis can have symptoms for 2-10 days and often recover fully.[14]
  • In paralytic poliomyelitis, muscle paralysis usually lasts 1-3 days, and in some cases up to 1 week.[15] Persistent weakness occurs in two thirds of patients.
  • Patients with severe form of paralytic poliomyelitis, and those who require mechanical ventilation have lower probability of achieving recovery.[2]
  • 5- 10% of patients with paralytic poliomyelitis die ofrespiratory muscles paralysis. The mortality rate varies with age: 2-5% in children, 15-30% in adults.
  • In the absence of support, bulbar poliomyelitis has a mortality rate of 25-75%, depending on the patient's age.[16] With adequate positive pressure ventilation, the mortality can be reduced to 15%.[17]
  • Permanent sequelae are uncommon in patients who have survived bulbar poliomyelitis.[2]

References

  1. ↑ Mueller S, Wimmer E, Cello J (2005). "Poliovirus and poliomyelitis: a tale of guts, brains, and an accidental event". Virus Res. 111 (2): 175–93. doi:10.1016/j.virusres.2005.04.008. PMID 15885840.
  2. ↑ 2.00 2.01 2.02 2.03 2.04 2.05 2.06 2.07 2.08 2.09 2.10 Mandell, Gerald (2010). Mandell, Douglas, and Bennett's principles and practice of infectious diseases. Philadelphia, PA: Churchill Livingstone/Elsevier. ISBN 0443068399.
  3. ↑ 3.0 3.1 "Poliomyelitis" (PDF).
  4. ↑ HORSTMANN DM (1949). "Clinical aspects of acute poliomyelitis". Am J Med. 6 (5): 592–605. PMID 18126001.
  5. ↑ BAKER AB (1949). "Bulbar poliomyelitis; its mechanism and treatment". Am J Med. 6 (5): 614–9. PMID 18126002.
  6. ↑ WEINSTEIN L (1957). "Cardiovascular disturbances in poliomyelitis". Circulation. 15 (5): 735–56. PMID 13427128.
  7. ↑ GALPINE JF, WILSON WC (1959). "Occurrence of myocarditis in paralytic poliomyelitis". Br Med J. 2 (5163): 1379–81. PMC 1990933. PMID 13826196.
  8. ↑ Mayo Clinic Staff (2005-05-19). "Polio: Complications". Mayo Foundation for Medical Education and Research (MFMER). Retrieved 2007-02-26. Check date values in: |date= (help)
  9. ↑ Ramlow J, Alexander M, LaPorte R, Kaufmann C, Kuller L (1992). "Epidemiology of the post-polio syndrome". Am J Epidemiol. 136 (7): 769–86. PMID 1442743.
  10. ↑ Dalakas MC, Sever JL, Madden DL, Papadopoulos NM, Shekarchi IC, Albrecht P; et al. (1984). "Late postpoliomyelitis muscular atrophy: clinical, virologic, and immunologic studies". Rev Infect Dis. 6 Suppl 2: S562–7. PMID 6330854.
  11. ↑ Dalakas MC, Elder G, Hallett M, Ravits J, Baker M, Papadopoulos N; et al. (1986). "A long-term follow-up study of patients with post-poliomyelitis neuromuscular symptoms". N Engl J Med. 314 (15): 959–63. doi:10.1056/NEJM198604103141505. PMID 3007983.
  12. ↑ Johnson RT (1984). "Late progression of poliomyelitis paralysis: discussion of pathogenesis". Rev Infect Dis. 6 Suppl 2: S568–70. PMID 6330855.
  13. ↑ FERRIS BG, AULD PA, CRONKHITE L, KAUFMANN HJ, KEARSLEY RB, PRIZER M; et al. (1960). "Life-threatening poliomyelitis, Boston, 1955". N Engl J Med. 262: 371–80. doi:10.1056/NEJM196002252620801. PMID 13822503.
  14. ↑ Neumann D (2004). "Polio: its impact on the people of the United States and the emerging profession of physical therapy" (PDF). The Journal of orthopaedic and sports physical therapy. 34 (8): 479–92. PMID 15373011. Reproduced online with permission by Post-Polio Health International; retrieved on 2007-11-10.
  15. ↑ Ritchie Russell, W.; Fischer-Williams, M. (1954). "RECOVERY OF MUSCULAR STRENGTH AFTER POLIOMYELITIS". The Lancet. 263 (6807): 330–333. doi:10.1016/S0140-6736(54)91084-3. ISSN 0140-6736.
  16. ↑ Miller AH, Buck LS (1950). "Tracheotomy in bulbar poliomyelitis". California medicine. 72 (1): 34–6. PMID 15398892.
  17. ↑ Template:Cite paper

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