Polio natural history, complications and prognosis

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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.[3]

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.[4] Typically symptoms in non-paralytic polio last for 2 to 10 days, and patients are expected to achieve complete recovery.[5]

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.[5][6][7]

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.[8]

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.[9]

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.[10]

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.[11]

Complications

Potential complications of poliomyelitis may include:[12][13][14][15][16][17][18][19]

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.[20]
  • Patients with abortive poliomyelitis often have a full recovery.[21]
  • Patients who develop aseptic meningitis, can expect symptoms to persist for 2-10 days, followed by complete recovery.[22]
  • Spinal poliomyelitis is rarely fatal.[23]
  • Muscle paralysis usually lasts 1-3 days, and in some cases up to 1 week.[24] Persistent weakness occurs in two thirds of patients with the paralytic form of the disease.
  • Patients with severe form of paralytic poliomyelitis, and those who require mechanical ventilation have less probability to recover.[25]
  • 5 to 10% of patients with paralytic poliomyelitis die due to the paralysis of respiratory muscles. The mortality rate varies with age: 2-5% in children, 15-30% in adults. In the presence of support, bulbar poliomyelitis has a mortality rate of 25-75%, depending on the patient's age.[26] When positive pressure ventilators are available, the mortality can be reduced to 15%.[27]
  • Permanent sequela is uncommon in patients who have survived bulbar poliomyelitis.[28]

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. ↑ Mandell, Gerald (2010). Mandell, Douglas, and Bennett's principles and practice of infectious diseases. Philadelphia, PA: Churchill Livingstone/Elsevier. ISBN 0443068399.
  3. ↑ Mandell, Gerald (2010). Mandell, Douglas, and Bennett's principles and practice of infectious diseases. Philadelphia, PA: Churchill Livingstone/Elsevier. ISBN 0443068399.
  4. ↑ Mandell, Gerald (2010). Mandell, Douglas, and Bennett's principles and practice of infectious diseases. Philadelphia, PA: Churchill Livingstone/Elsevier. ISBN 0443068399.
  5. ↑ 5.0 5.1 "Poliomyelitis" (PDF).
  6. ↑ Mandell, Gerald (2010). Mandell, Douglas, and Bennett's principles and practice of infectious diseases. Philadelphia, PA: Churchill Livingstone/Elsevier. ISBN 0443068399.
  7. ↑ HORSTMANN DM (1949). "Clinical aspects of acute poliomyelitis". Am J Med. 6 (5): 592–605. PMID 18126001.
  8. ↑ Mandell, Gerald (2010). Mandell, Douglas, and Bennett's principles and practice of infectious diseases. Philadelphia, PA: Churchill Livingstone/Elsevier. ISBN 0443068399.
  9. ↑ Mandell, Gerald (2010). Mandell, Douglas, and Bennett's principles and practice of infectious diseases. Philadelphia, PA: Churchill Livingstone/Elsevier. ISBN 0443068399.
  10. ↑ BAKER AB (1949). "Bulbar poliomyelitis; its mechanism and treatment". Am J Med. 6 (5): 614–9. PMID 18126002.
  11. ↑ Mandell, Gerald (2010). Mandell, Douglas, and Bennett's principles and practice of infectious diseases. Philadelphia, PA: Churchill Livingstone/Elsevier. ISBN 0443068399.
  12. ↑ Mandell, Gerald (2010). Mandell, Douglas, and Bennett's principles and practice of infectious diseases. Philadelphia, PA: Churchill Livingstone/Elsevier. ISBN 0443068399.
  13. ↑ WEINSTEIN L (1957). "Cardiovascular disturbances in poliomyelitis". Circulation. 15 (5): 735–56. PMID 13427128.
  14. ↑ GALPINE JF, WILSON WC (1959). "Occurrence of myocarditis in paralytic poliomyelitis". Br Med J. 2 (5163): 1379–81. PMC 1990933. PMID 13826196.
  15. ↑ 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)
  16. ↑ 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.
  17. ↑ 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.
  18. ↑ 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.
  19. ↑ Johnson RT (1984). "Late progression of poliomyelitis paralysis: discussion of pathogenesis". Rev Infect Dis. 6 Suppl 2: S568–70. PMID 6330855.
  20. ↑ 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.
  21. ↑ Mandell, Gerald (2010). Mandell, Douglas, and Bennett's principles and practice of infectious diseases. Philadelphia, PA: Churchill Livingstone/Elsevier. ISBN 0443068399.
  22. ↑ 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.
  23. ↑ Silverstein A, Silverstein V, Nunn LS (2001). Polio, Diseases and People. Berkeley Heights, NJ: Enslow Publishers, 12. ISBN 0-7660-1592-0.
  24. ↑ 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.
  25. ↑ Mandell, Gerald (2010). Mandell, Douglas, and Bennett's principles and practice of infectious diseases. Philadelphia, PA: Churchill Livingstone/Elsevier. ISBN 0443068399.
  26. ↑ Miller AH, Buck LS (1950). "Tracheotomy in bulbar poliomyelitis". California medicine. 72 (1): 34–6. PMID 15398892.
  27. ↑ Template:Cite paper
  28. ↑ Mandell, Gerald (2010). Mandell, Douglas, and Bennett's principles and practice of infectious diseases. Philadelphia, PA: Churchill Livingstone/Elsevier. ISBN 0443068399.

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