Acute Flaccid Paralysis (AFP)

Acute Flaccid Paralysis (AFP)

A clinical syndrome characterised by rapid onset of weakness, progressing to maximum severity within 4 weeks characterised diminshed/absent deep tendon reflexes with intact/reduced sensory functions.

  • Global Polio Eradication Initiative case definition for AFP due to polio: A child aged <15 years or any case of paralytic illness in a person of any age when polio is suspected.

Aetiology

  • Hypokalemia
  • Guillain Barre Syndrome
  • Transverse myelitis
  • Traumatic neuritis
  • Acute paralytic poliomyelitis
  • Non-polio virus: Coxsackie A, B, ECHO, including mumps
  • Peripheral neuropathy:
    • Diabetes, drugs, heavy metals (Pb, Hg), post-diphtheric

Diagnosis

Investigations

Acute Flaccid Paralysis (AFP) Surveillance

All cases should be reported to a WHO Surveillance Medical Officer
  • Conditions to be notified:
    • All AFP cases (within 6 months)
    • Isolated facial palsy
    • Isolated bulbar palsy
    • Unproved hypokalemia
    • Neck flop
    • Floppy baby
    • Flaccid hemiplegia
    • Encephalitis
    • Postictal weaknessTodd’s paralysis
    • Post-diphtheritic polyneuritis
  • Cases to be investigated within 48 hours of notification by a trained medical officer
    • Detailed medical history
    • Clinical examination
    • Collection & transportation of stool specimens for testing
      • 2 stool specimens (Ideally within 14 days of paralysis-onset, 24 hrs apart, 8g each; up to 60 days)
      • Collected in clean, dry, screw-capped container
      • Transported in cold-chain
  • 60-day follow-up examination
  • Analysis of lab-results
  • Case classification

Differential diagnosis:

 PoliomyelitisGuillain-BarreTransverse myelitisTraumatic neuritis
FeverPresentMaybe
(prodromal illness)
Maybe
(prodromal illness)
Absent
SymmetryAsymmetricalSymmetricalSymmetricalAsymmetrical
SensationsIntactVariableImpairedMaybe impaired
Respiratory insufficiencyMaybeMaybeMaybeAbsent
Cranial nervesPresent (in Bulbar & Bulbospinal variants only)Usually affectedAbsentAbsent
Radicular signsMaybePresentAbsentAbsent
Bladder, bowel complaintsAbsentTransient (due to autonomic dysfunction)PresentAbsent
Nerve conductionMaybeAbnormalNormalAbnormal
CSFLymphocytic pleocytosis
Normal/increased protein
Abumino-cytologic dissociationVariableNormal
MRI spineNormalNormalCharacteristicNormal

Muscle disorders:

  • Inflammatory myopathy
  • Periodic paralysis
  • Hypokalemia
  • Infections

Neuromuscular junction disorders:

  • Myasthenia gravis
  • Botulism
  • Eaton-Lambert syndrome

Neuropathies:

  • Guillain-Barre s.yndrome
  • Traumatic neuritis
  • Postdiphtheric neuropathy
  • Porphyria
  • Vasculitis

Anterior horn-cell disorders:

  • Poliomyelitis
  • Nonpolio enteroviruses

Spinal cord disorders:

  • Transverse myelitis
  • Spinal cord compression
  • Trauma

Management

Public health measures:

Immediate reporting to District Immunization/Surveillance Officer
  • COLLECTION OF STOOL:
    • 2 samples, 8g each, at 24-48 hour interval within 14 days of onset of paralysis
    • If case registered after 14 days:
      • Collect by 60 days
    • Transport at < 8°C

Treatment:

  • Monitor:
    • Pulse, BP, convulsion
  • Care of bladder & bowel:
    • Catheterization, laxatives & enema
  • Care of skin:
    • Maintain hygiene
    • Frequent position change (2-3 hours)
  • Positioning:
    • Firm bed (prevent sagging of spine)
    • Lower limbs:
      • Legs- flexion; knee- 5-10° flexion; foot- 90°
      • Support with pillows
    • Upper limbs:
      • Abduction of shoulder, flexion of elbow, hand in functional position
  • Management of pain & spasm:
    • Complete bed rest
    • IM injection & massage
  • Physiotherapy
  • Maintain nutrition & hydration:
    • IV → Nasogastric → Oral
  • Monitor respiratory paralysis:
    • Indications for ICU admission:
      • Paralysis of:
        • Intercostal muscle/diaphragm
        • Pharyngeal/laryngeal muscles
        • Vital centers
      • Encephalitis or coma

AFP Surveillance

  • Reporting unit
  • Case notification of AFP
  • Case investigation within 48 hours of onset
  • Outbreak control immunisation or ring immunisation
  • 60 days AFP follow-up


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