11. Acute Flaccid Paralysis – Differential Diagnoses.pptx

PEDIATRICS

1. Approach to Clinical Examination of an AFP case

2. AFP : Definition Sudden onset weakness and floppiness in any part of the body in a child < 15 years of age or paralysis in a person of any age, in whom polio is suspected Clinically…

3. Reporting…

4. UMN LMN

5. Anterior Horn Cells Radicle Motor Nerve Myoneural jn. Muscle Motor Unit

6. Approach to diagnosis of AFP

7. History Reliable informant Accurate Focused Relevant Almost half the diagnosis is made

8. Pediatric history taking Birth history Developmental details Family history : - consanguinity - sibling death / abortions - similar disease

9. Birth history Institutional / home delivery Mode : vaginal / LSCS Assisted or not H/o delayed cry Birth weight Gestational age Hospitalization in post-natal period

10. Milestones Detailed history required Comment on other milestones too if delay is suspected

11. Head (neck) holding 3 mo Rolling over 5-6 mo Sitting with support 5 mo Sitting without support 6 mo Crawling 7-8 mo Standing with support 9 mo Standing without support 12 mo Walking 13 mo Grasps a rattle 4 mo Bidextrous grasp 5 mo Palmar grasp 7 mo Pincer grasp 9 mo Turns head to sound 1 mo Cooing 3 mo Monosyllables 6 mo Bisyllables 9 mo 2 words with meaning 12 mo 10 words with meaning 18 mo Simple sentence 24 mo Telling a story 36 mo Social smile 2 mo Recognizes mother 3 mo Smiles at mirror image 6 mo Waves “bye-bye” 9 mo Plays a simple ball game 12 mo Knows gender 3 year

12. Examination: Prerequisites Put child at ease, stand on right side Be gentle Patient should be warm & comfortable Have love , patience & tolerance Reassure ‘ no harm ’ Appropriately undress Be a keen observer & utilize your senses

13. Clinical examination General Neurological Systemic General examination Head to toe No set pattern Individualize Painful / uncomfortable exam. at the end

14. Measurements Weight Head circumference Limb measurements Upper limb Mid-arm Acromian to Olecranon (both sides) Fore-arm Olecranon to Pisiform Lower limb Mid-thigh ASIS to medial condyle (both sides) Mid-calf Medial condyle to medial malleolus Age HC (cm) At birth 32-35 3 mo 40 6 mo 43 1 yr 47 2 yr 49 3 yr 50 4 yr 50.4 5 yr 50.8 12 yr 52 Adult 54-56

15. Neurological exam. Higher functions Signs of meningeal irritation Cranial nerves Motor system Sensory system Cerebellar function Gait & posture Autonomic system Spine & cranium

16. Higher functions C onsciousness O rientation M emory I ntelligence S peech COMIS

17. Meningeal signs

18. Cranial nerves I (Olfactory): sense of smell in each nostril II (Optic) : - visual acuity - field of vision - colour vision - fundus examination III (Oculomotor) - look at eyes at rest IV (Trochlear) - observe eye movements VI (Abducens) - squint, nystagmus, diplopia III : - ptosis - dilated fixed pupils - lateral deviation - inability to look up - eye displaced outwards & downwards

19. Eye movements

20. Eye movements

21. Cranial nerves IV : - impaired downward movment - upward & outward deviation of eye VI : - longest intracranial course - false localizing sign in raised ICP - inability to move eye outwards

22. Ptosis LR palsy

23. Lateral rectus (6 th nerve) palsy Longest intracranial course Most commonly affected in raised ICT

24. Cranial nerves V ( Trigeminal) : (a) Motor component : - supplies muscles of mastication - observe chewing/sucking/ opening & closing of mouth - jaw deviated to paralysed side - cannot move jaw side to side - ask patient to clench teeth - feel temporalis/ masseter while biting

25. Cranial nerves V ( Trigeminal) : (b) Sensory component : - supply face, conjunctiva, cornea & anterior 2/3 rd of tongue - loss of corneal / conjunctival reflex - sensory loss over scalp, cheek, mandible - loss of pain sensation over anterior 2/3 rd of tongue

26. Facial (VII) nerve

27. Cranial nerves VII (Facial) : (a) Motor part : - facial asymmetry (esp. in crying child) - wide palpebral fissure - loss of forehead wrinkling - decreased nasolabial folds - angle of mouth pulled to healthy side - drooling of saliva - ask to whistle, blow, close eyes, show teeth

28. FACIAL PALSY ®

29. Cranial nerves VII (Facial) : (a) Sensory part : - loss of taste over anterior 2/3 rd of tongue - test with sugar, salt, lemon & quinine in order - salivation & tears may be affected - hyperacusis may occur LMN type : paralysis of whole face UMN type : - lower half of face paralysed - eyes & forehead partially spared - emotional expressions of face preserved - usually seen in hemiplegia

30. Facial palsy - causes Congenital : Aplasia of facial nerve nuclei D/D : Aplasia of depressor anguli oris muscle

31. Facial palsy - causes Acquired : Bell’s palsy – commonest Traumatic / perinatal insult Middle ear pathology (ASOM/CSOM, tumor) Parotitis , parotid tumor Poliomyelitis ( Bulbar polio) Metastatic infiltration H/O fever, URI, rash, trauma, perinatal insult, ear discharge, otalgia , parotid or cheek swelling

32. Cranial nerves VIII ( Vestibulo -cochlear) : - hearing loss - tinnitus - hyperacusis - vertigo - infants : startle, eye blinking, turning of head

33. Cranial nerves IX (Glossopharyngeal) & X ( Vagus ) : Supply pharynx, larynx & soft palate IX cr.n . supplies post. 1/3 rd of tongue C/O- dysphagia, nasal regurgitation , nasal twang Loss of swallowing reflex (drooling/ choking), sucking Loss of gag reflex, m ovement of palate when saying `ah’ or crying In-effective/weak cough reflex Aphonia / hoarseness of voice

34. Cranial nerves XI (Spinal-accessory ) : 2 parts (a) spinal : - supplies trapezius & SCM - inability to shrug shoulder against resistance - weakness in chin rotation to opp.side (b) accessory : - Supplies motor fibers to vagus (larynx, pharynx) for respiratory tract, heart & abdominal viscera

35. Cranial nerves XII (Hypoglossal) : deviation of protruded tongue to paralysed side wasting & fasciculations ( in LMN lesion) 6 th & 12 th cranial n.palsy

36. Bulbar paralysis 9 th , 10 th , 11 th & 12 th cranial n. involved C/F : - drooling of saliva - pooling of secretions - dysphagia - nasal regurgitation - dysarthria - nasal twang Respiratory & vasomotor centre involved

37. Motor system exam. Bulk of muscle Tone Power Reflexes Involuntary movements Trophic changes

38. Muscle bulk By inspection & palpation Wasted / atrophic muscles : soft, flabby, thin Fibrotic muscles feel hard & inelastic Pseudo-hypertrophy – eg. DMD Confirmed by limb circumference measurements

39. WASTING OF LEFT LOWER LIMB

40. Muscle tone State of partial contraction of a muscle Assessed by : observing the limb position & posture palpation of muscle resistance to passive movements shaking the unsupported limb

41. FLOPPY INFANT

42. NECK FLOP

43. SPASTIC HEMIPARESIS (L)

44. SCISSORING OF LOWER LIMBS

45. Muscle power Charting of muscle power Grade No flicker Flicker + 1 Movement possible with gravity eliminated 2 Movement possible against gravity 3 Movement possible against gravity and some resistance 4 Normal power 5

46. Muscle power grading

47. Reflex An involuntary & nearly immediate movement in response to a stimulus mediated via the reflex arc

48. Reflexes Reflex Sensory Motor Pupillary / light II III Accomodation II III Jaw jerk V V Corneal / blink V VII Vestibulo-ocular VIII III, IV, VI + Gag IX X

49. Superficial reflexes Reflex Normal response CNS segment Corneal Prompt closure of eye 5 th & 7 th cranial n. Upper abdominal Umbilicus moves up & towards the area stroked + contraction of abdominal wall T 7-9 Lower abdominal Umbilicus moves down T 11-12 Cremasteric Scrotum elevates T 12 L 1 Plantar Flexion of big toe S 1

50. Deep tendon reflexes Reflex Elicited at Normal response CNS segment Jaw jerk Midpoint of chin Biceps Biceps tendon Contraction of biceps C 5-6 Triceps Triceps tendon Extension of elbow C 6-8 Brachio - radialis Styloid process Flexion of elbow & pronation of forearm C 5-6 Knee Patellar tendon Extension of knee L 2-4 Ankle Achilles tendon Plantar flexion of ankle L 5 ,S 1

51. Deep tendon jerks - Grading Absent (even on reinforcement) Present (as normal ankle jerk) 1+ (+) Brisk ( as normal knee jerk) 2+ (++) Very brisk 3+ (+++) Clonus 4+ (++++) Words like diminished, normal and sluggish should not be used

52. UMN vs. LMN lesion UMN lesion LMN lesion Tone Increased / rigidity Reduced / lost Power Reduced Markedly reduced DTR’s Brisk ± clonus Sluggish / absent Plantars Extensor Flexor / absent Muscle wasting Minimal / absent Marked Involuntary movements Convulsions Fasciculations

53. Sensory system Superficial : touch, pain, temperature Deep : vibration, position Cortical : - tactile localization - sensory inattention - 2 point discrimination - Astereognosis , Barognosis - Graphesthesia

54. Cerebellar signs Ataxic gait Heel-knee test Tandem walking Finger-nose test / past-pointing Rebound phenomenon Dysdiadochokinesia Scanning speech Intention tremors Nystagmus

55. Gait Circumduction / spastic / hemiplegic High-stepping Ataxic / staggering / drunken Waddling Limping Scissoring

56. Autonomic system Instability of vital signs - Pulse - RR - BP - Temperature ↓ or ↑ sweating ↓ salivation or lacrimation Sphincteric disturbances Trophic changes TROPHIC ULCER (R) IN TRAUMATIC NEURITIS

57. Spine & Cranium Spine - shape - deformity - swelling, gibbus - tuft of hair, pilonidal sinus - tenderness Cranium – size, shape, symmetry - swelling - suture & fontanelles

58. Systemic examination Respiratory Cardiovascular Abdominal Others

59. Hot AFP case “All such cases, which in the opinion of DIO/SMO, after examination, look like Polio are labelled as Hot Case ” Age < 5 yrs + H/O fever at onset of paralysis + asymmetrical proximal & patchy paralysis Age < 5 years with rapidly progressive paralysis leading to bulbar involvement and death

60. To summarize… Clinical work-up needs your personal attention High quality documentation & clinical evaluation needed Tender, love & care is the key

61. Motor unit Possible sites of involvement in AFP

62. Muscle disorders Inflammatory myopathy Periodic paralysis Hypokalemia Infections NM junction disorders Myasthenia gravis Botulism Neuropathies GB syndrome Traumatic neuritis Post-diphtheritic neuropathy Porphyria AHC disorders Poliomyelitis Non-polio enteroviruses Spinal cord disease Transverse myelitis Spinal cord compression Trauma Differential diagnosis of AFP

63. Differential diagnosis of AFP Non-polio e n t e r ovi r al diseases Post- Di p h theri t ic neuropathy Com m on causes of AFP Guillain- Barre’ s yn d r o me Poliomyelitis T r a n sv e r se myelitis T r a u m a tic neuritis

64. Guillain-Barré syndrome Acute polyneuropathic paralysis Affects peripheral nervous system Preceding events (1-3 weeks): URI GI infection Vaccination

65. Guillain-Barré syndrome Classic ‘3A Triad’ A scending weakness A reflexia / hyporeflexia - Hallmark A tonia / hypotonia B/L symmetrical weakness Usually starts in LL, then UL Cranial n. involved-9,10,7,3,4,6 Respiratory muscle involvement Diaphragm (phrenic n. invol.) Cardiac arrest Aspiration pneumonia

66. GB syndrome-Investigation Early – abnormal NCV Late (after 1 st week) - CSF ( albumino -cytological dissociation)

67. Poliomyelitis Humans – only reservoirs Incubation period 7-10 days (range 4-35 days) Predominant transmission mode – faeco -oral Virus shed in stools – 6 to 8 weeks

68. Clinical suspicion of Polio Age : 6 month – 5 years Low socio-economic status, poor sanitation High fever at onset of paralysis Acute, asymmetrical , flaccid , motor paralysis Weakness is patchy , proximal > distal

69. Types of Polio infections Inapparent – 90 to 95% Abortive – 4 to 8% Non-paralytic aseptic meningitis – 1 to 2% Paralytic – 0.5 to 1% spinal bulbar bulbospinal Polio encephalitis

70. Polio Compatible case H/O fever at onset, diarrhea Sudden onset limp O/E : ↓ tone, power & reflexes - asymmetrical (if >1 limb involved) - patchy paralysis / monoparesis - bulbar paralysis - no sensory loss - residual paralysis / wasting at 60 days Invx : abnormal NCV, neurogenic EMG from 3 rd week

71. Transverse myelitis Caused by inflammation of spinal cord Acute symmetrical flaccid paralysis Anaesthesia of lower limbs with sensory level (band like sensation) Reflexes – absent (early), hyper (late) Early bladder & bowel involvement

72. Traumatic Neuritis Caused by injury to nerve Acute asymmetrical flaccid paralysis H/O I/M injection in gluteal region / arm Sensory symptoms present

73. Traumatic Neuritis Sciatic nerve injury :- ankle jerk absent / foot drop high stepping gait trophic ulcers foot Radial nerve injury :- wrist drop Muscular atrophy of affected limb