ACUTE FLACCID PARALYSIS

Introduction Acute Flaccid Paralysis (AFP) occurs when there is rapid evolution of motor weakness (< than 4 days), with a loss of tone in the paralysed limb. This excludes weakness due to trauma and spastic paralysis. AFP is a medical emergency as unnecessary delays can result in death and disability. Children with AFP need to be assessed and managed carefully. Figure 1 describes a simple algorithm to follow. AFP surveillance in children collecting stools for enterovirus in children with AFP is an important part of the Global Polio Eradication Initiative (GPEI) for Malaysia to remain a polio-free country we need to prove that none of our cases of AFP are caused by poliovirus infection. To do this we have to report enough cases, send stools for enterovirus isolation using a standardised protocol, and follow up children with AFP to determine the outcome. the new target background rate for AFP in the GPEI is 2 per 100,000 children below age 15 per year
Table 1. Protocol for AFP surveillance in Malaysia Step Timing Description Case Detection at diagnosis Follow case definition for AFP Case Reporting within 24 hours Fax forms to 03-2693 8094 (Virology Unit, IMR; Tel no: 03-2616 2677) 2 stool specimens collected no less than 24 hours apart

NEUROLOGY

Timing of stool within 2 weeks specimens of onset of paralysis Collection of Fresh stool, or rectal swabs containing fecal material specimens (at least 8g size of an adult thumb). Place in a sterile glass bottle Transport of as soon as able Maintain a cold chain of 2 - 8 C. Transport in dry ice if stools transportation will take > 24 hours Caution: avoid desiccation, leakage; ensure adequate documentation Follow up of 60 days from To determine whether there is residual paralysis on follow up patients paralysis

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Figure 1. Clinical approach to children with AFP

NEW ONSET Difficulty in walking CNS Symptomatology No demonstrable CNS signs or motor weakness Demonstrable Lower limb Motor Weakness CNS Disorder Musculoskeletal disorder

NEUROLOGY

Clinical Questions Sphincters ? Preserved Sensory loss ? None Reflexes ? Reduced or normal MUSCLE

Preserved Glove & Stocking Absent

Preserved Dermatomal

Affected Dermatomal

Absent, reduced or normal SPINAL CORD

Clinical Localisation

PERIPHERAL NERVE unilateral bilateral

Differential post viral myositis Diagnosis periodic paralysis toxic myositis

enteroviral

infection local trauma

Guillain Barr

acute transverse
myelitis

syndrome toxic neuropathy

spinal cord /

extraspinal tumour malformation

arteriovenous

spinal cord stroke extradural abscess spinal tuberculosis spinal arachnoiditis

Investigations Required AFP workup creatine kinase serum electrolytes urine myoglobin Required AFP workup Nerve conduction study Optional MRI lumbosacral plexus, sciatic nerve Required AFP workup CSF: cells, protein Nerve conduction study Forced vital capacity Required AFP workup URGENT Spinal cord MRI Optional (as per MRI result) TB workup CSF : cells, protein, sugar, culture, TB PCR, cryptococcal antigen oligoclonal bands ESR, C3,C4, antinuclear factor

Notes: 1. headache, vomiting, seizures, encephalopathy, cranial nerve deficits, ataxia, brisk tendon reflexes, upgoing plantar response 2. soft tissue, joint or bony causes of walking difficulty 3. GBS in children may present in a variety of ways. Refer next page. 4. Standard spinal MRI must begin with a screening sagittal T2-weighted image of the whole spine, then adequate study of the affected area(s) in both sagittal and axial planes. Contrast with gadolinium is often needed.

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