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Nonparalytic poliomyelitis is similar to other forms of enteroviral meningitis; the distinction is made serologically Acute flaccid paralysis is the term used in the developing world for the variety of neurologic illnesses that both include and mimic poliomyelitis Acute flaccid paralysis due to poliomyelitis is distinguished by the greater frequency of fever and asymmetric neurologic signs Acute inflammatory polyneuritis (Guillain Barr syndrome), Japanese B virus encephalitis, West Nile virus infection, and tick paralysis may resemble poliomyelitis In Guillain Barr syndrome (see 24), the weakness is more symmetric and ascending in most cases, but the Miller Fisher variant is quite similar to bulbar polio Paresthesias are uncommon in poliomyelitis but common in Guillain Barr syndrome The cerebrospinal fluid usually has a high protein content but normal cell count in Guillain Barr syndrome
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Urinary tract infection, atelectasis, pneumonia, myocarditis, paralytic ileus, gastric dilation, and pulmonary edema may occur Respiratory failure may be a result of paralysis of respiratory muscles, airway obstruction from involvement of cranial nerve nuclei, or lesions of the respiratory center
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Given the epidemiologic distribution of poliomyelitis and the continued concern about vaccine-associated disease with the oral live vaccine, recommendations for prevention were modified Currently in the United States, the inactive (Salk) parenteral vaccination is used for all four doses (at ages 2 months, 4 months, and 6 18 months and at 4 6 years) Inactivated vaccine is also routinely used elsewhere in the developed world Oral vaccines are limited to usage for outbreak control, travel to endemic areas within the ensuing month, and protection of children whose parents do not comply with the recommended number of immunizations The advantages of oral vaccination are the ease of administration, low cost, effective local gastrointestinal and circulating immunity, and herd immunity Routine immunization of adults in the United States is no longer recommended because of the low incidence of the disease Exceptions include adults not vaccinated within the prior decade who are exposed to poliomyelitis or who plan to travel to endemic areas (mentioned above) These adults should be given inactivated poliomyelitis vaccine (Salk) as should immunodeficient or immunosuppressed individuals and members of their households In the developing world, the interval between oral polio vaccine doses should probably be longer than 1 month (because of interference from enteric pathogens) Intramuscular injections should be routinely avoided during the month following oral poliomyelitis vaccination to prevent provocation paralysis The Sabin vaccine is associated with a low rate of vaccine-associated poliomyelitis (1 in 750,000 recipients) due to mutations leading to neurovirulence Out-
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The peripheral white blood cell count may be normal or mildly elevated Cerebrospinal fluid pressure and protein are normal or slightly increased Glucose is not decreased White blood cells usually number < 500/mcL and are principally lymphocytes after the first 24 hours Cerebrospinal fluid is normal in 5% of patients The virus may be recovered from throat washings (early) and stools (early and late) Neutralizing and complement-fixing antibodies appear during the first
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breaks of vaccine-derived poliomyelitis occurred in Hispaniola (both Haiti and the Dominican Republic) from 2000 to 2001 with type 1 isolates and Madagascar with type 2 isolates These incidents serve as a reminder of the need to maintain high levels of immunization coverage even in the absence of overt disease Strategies to decrease or replace the current trivalent oral vaccine include possibly combining the inactivated poliovirus vaccine with the oral vaccine or use of monovalent type 1 oral vaccines, with success reported with the latter in India and Egypt
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CMDT 2008
4 Rubella
ESSENTIALS OF DIAGNOSIS
Exposure 14 21 days before onset Arthralgia, particularly in young women No prodrome in children, mild prodrome in adults; mild symptoms (fever, malaise, coryza) coinciding with eruption Posterior cervical and postauricular lymphadenopathy 5 10 days before rash Fine maculopapular rash of 3 days duration; face to trunk to extremities Leukopenia, thrombocytopenia
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