A

CASE
PRESENTATION
ON
POLIOMYELITIS
PRESENTED TO:
ALBERTO GILBERT GUZMAN, PTRP

PRESENTED BY: BSN 1V

ARJAN, MUJIBA
GALAROSA, WILMAE S.
GAWARAN , MARK ANTHONY
MOHAMMAD, JAIMA
SARDENIA CHRISTINE MARIE
organ affected

CENTRAL NERVOUS SYSTEM

THE BRAIN

Polioviruses can attack motorneurons in the anterior horn of the spinal cord
and in the bulbar area.
NORMAL FUNCTION
Central Nervous System
Anatomy and Physiology I
 
Spinal Cord
–  Located within the dorsal vertebral column
–  From base of the brain to the pelvis
•   In humans the posterior few segments are filled with nerves that supply the pelvis, buttocks &
legs
–  Gray matter around a central canal - butterfly shape
•   Cell bodies, dendrites & synapses
–  White matter surrounds gray matter
•   Bundles of myelinated axons that connect different parts of the cord
Spinal Nerves - Sensory & motor
•  Dorsal root - sensory - dorsal root ganglion (sensory cell bodies)
•  Ventral root - motor 
 
Spinal Nerves
–  31 pairs
Lobes of the Brain
–  Boundaries between not always clearly delineated - therefore just indicate general regions
•   Frontal lobe
•   Parietal lobe
•   Occipital lobe
•   Temporal lobe
Brain Architecture
–  Front part of the brain increases in size & surface area from fish to mammals
–  The surface thrown into folds  - gyri (gyrus - singular)
–  The grooves  between the folds are sulci (sulcus - singular)
Cellular organization
•    Tracts occur on the surface & deeper
•    Gray matter - forms distinct collections of cell bodies - nuclei
•    Cortex - opposite of spinal cord
 –  Outside - gray matter with white below (complex tangles of tracts below - with deep nuclei)
 Mammalian Brain
•    Forebrain - prosencephalon
–  Telencephalon - cerebral hemispheres - higher functions, motor control & sensory processing
Diencephalon
•     Thalamus - sensory relay
–   Lateral geniculate - visual
–   Medial geniculate - auditory
•     Hypothalamus - homeostasis control center
•     Pituitary gland - master endocrine gland
Basal ganglia - Motor planning & Control (Distinct nuclei)
Limbic system - Emotions & Memory (distinct nuclei)
 Midbrain - Mesencephalon
•    Tectum - sensory processing center
–  Superior colliculus - oculomotor reflexes (visual processing - lower vertebrate)
–  Inferior colliculus - Auditory relay & processing
–  Tegmentum - orientation reflexes & auditory
–  Red nucleus - postural reflexes & motor control
–  Substantia nigra - postural reflexes & motor control & linked with limbic system
Mammalian Brain
–  Hindbrain - Rhombencephalon
•   Metencephalon
–  Cerebellum - coordination & learning
–  Pons - control of respiration
–  Medulla oblongata - control of respiration, heart rate, blood pressure, vomiting & coughing 
Central Core of the Brain
–  Tube expands during development - forms the ventricles or chambers of the brain
–  Fourth ventricle - chamber of the hindbrain
–  Third ventricle - chamber of the forebrain
•  Connected to the 4th ventricle by the cerebral aqueduct - passes through midbrain
–  Right & left ventricles - expansions of the third ventricle in the telencephalon
 External Covering of the Brain
–  Meninges - three membranes
–  Outermost - dura mater - tough inelastic bag surrounds the brain & spinal cord
–  Middle most membrane - arachnoid membrane - appearance & consistency resembling a spider
web
–  Innermost - pia mater - thin membrane that adheres closely to the surface of the brain
–  Pia mater is separated from the arachnoid by fluid filled subarachnoid space  
Cerbrospinal Fluid - CSF
–  Produced by chroid plexus  in the walls of the ventricles of the cerebral hemispheres
–  CSF flows from the paired ventricles then to the third & fourth ventricles
then to the central canal of the spinal cord
–  CSF escapes into the subarachnoid space via small apertures near the base of the
cerebellum
–  In the subarachnoid space, CSF is absorbed into the blood
•  Clear colorless fluid containing ions & little protein fills the central canal of the
    

spinal cord and the ventricles

•  Also circulates over surface of the brain - acts as shock absorber
The Lower Brain - Brain Stem
–  Medulla  - from spinal cord
–  Pons - from anterior medulla - bulging area - external surface ribbed
–  Cranial nerves 5 through 12 arise from the brain stem
–  Fiber tracts
•  Pyramidal tracts - ventrally located - motor
–  Corticospinal - cortex to spinal cord
–  Spinocortical - spinal cord to cortex
–  Reticular system - loose network of of neurons - reticular activating system
•  Modulate sensation of pain
•  Modulate certain postural reflexes & muscle tone
•  Control breathing & heart rate
•  Regulate the level of brain arousal & in humans consciousness
•  Receives massive sensory input
 The Cerebellum
–  Part of the hindbrain - not brain stem
–  Connected to pons via cerebral peduncles
•  Represent thousands of fibers going into or out of the cerebellum
–  A central point for motor organization. Yet it does not initiate movement and movement
can be generated in the absence of it
–  The cerebellum modulates or reorganizes motor commands - and by coordinating diverse
signals, it obtains the maximum efficiency from them
–  Lesions - produce disturbances in the coordination of limb and eye movements and
disorders of muscle tone and posture
–  Principal cell - Purkinje cell - projects to deep cerebellar nuclei
 The Midbrain
–  Sits between hindbrain & forebrain
 –  Major thruway for axon tracts that connect the above two regions
–  Tectum in lower vertebrates - visual processing
•   In mammals - same area called superior collculus
–  Inferior colliculus - dorsal surface of midbrain - auditory
–  Tegmentum - below the aqueduct - largest midbrain area
•   Red nucleus & substantia nigra - orientation reflexes
The Diencephalon
–  Lower part of the forebrain
–  Parts - Thalamus & hypothalamus
–  Thalamus - major relay for sensory information
•   Lateral geniculate nucleus -paired - visual input
•   Medial geniculate nucleus - paired - auditory input
–  Hypothalamus - regulates internal environment
•   Initiate or suppress behaviors to maintain homeostasis
•   Regulate pituitary gland - which regulates endocrine system
•   Controls autonomic nervous system - to regulate homeostasis
The Telencephalon
–  Upper part of the forebrain
–  Half the brain volume
–  Cerebral hemispheres - paired lobes - together called cerebrum
•   Outer layers - cell bodies , dendrites & synapses - gray matter - cerebral cortex
•   Hemispheres joined by corpus callosum
•   Central sulcus - divides hemispheres into anterior & posterior halves
–  Precentral gyrus - just ahead of the central sulcus - motor cortex
–  Postcentral gyrus - sensory processing from body surface & muscles
–  The basal ganglia nuclei clustered around the thalamus
•   Functions as an entity partially devoted to sequencing individual motor programs into smooth
series of actions
•   Gate sensory influences into motor areas
•   Regulate sensimotor interactions in a way that determines which sensory stimuli are use to
initiate motor actions and which are disregarded
•   Components
–  Striatum (caudate + putamen)
–  Globus pallidus
–  Subthalamic nucleus - in diencephalon
–  Substantia nigra - in midbrain
Autonomic Nervous System
–  Sympathetic NS
•   Parasympathetic NS
•   Enteric NS
•    Neurons of Autonomic Nervous System
–  Preganglionic
•   Cell bodies in spinal cord or brain stem
 –  Postganglionic
•   Cell bodies in peripheral autonomic ganglia
–  Visceral Afferents
 
 Peripheral Sympathetic NS
–  Preganglionic - in thoracic & upper lumbar spinal cord
•  Axons run in autonomic ganglia
•  Postganglionic
–  Axons in sympathetic chain or paravertebral ganglia
•  Effector organs
–  Blood vessels, hair, viscera, pupils, cardiac muscle, glands
 Sympathetic NS
–  Inhibitory effect on non sphincter muscle of viscera, digestive glands & SM of bronchi.
–  All other effects excitatory!
Pattern of Sympathetic Connection
• Parasympathetic NS
    

–  Preganglionic - in sacral cord and brain stem

•  Vagus (CN X) - 75% of parasymp. outflow
–  Postganglionic - short fibers
–  All parasymp. innervated organs also sympathetically innervated
•  e.g. bladder, rectum,GI tract, heart, lungs, lacrimal & salivary glands
Parasympathetic NS
– Not all Sympathetically. innervated structures are parasympathetically.
 

innervated
– Exceptions
•  Entire vascular system, adrenal medulla & pilomotor muscle - only sympathetically
innervated.
Functions of the Autonomic NS
–  Sympathetic and Parasympathetic systems are antagonistically organized
–  Sympathetic - largely fight or flight response
•  Works with adrenal medulla - epinephrine
–  Parasympathetic - antagonizes sympathetic activity
•  Not normally activated as a whole
Neurotransmitters of the Autonomic NS
–  All preganglionic fibers - cholinergic
–  Postganglionic parasympathetic fibers - cholinergic
 –  Postganglionic sympathetic fibers - NE - adrenergic
–  Some sympathetic - cholinergic
•  Sweat glands & blood vessels of skin and skeletal muscle

DEFINITION:
- is an acute infectious disease caused by any of the three types of Poliomyelitis virus which affects chiefly the
anterior horn cells of the Spinal cord and the medulla, cerebellum and midbrain.
- Characterized by two febrile episodes, a minor and major illness separated by a remission of one or two days
followed by varying degrees of muscle weakness or occasionally a progressive Paralysis that ends fatally.
SYNONYMS:
Acute Anterior Poliomyelitis; Heine-Medin Disease: Infantile Paralysis.
ETIOLOGY AND EPIDEMIOLOGY:
- the causative virus is poliovirus (Legio Debilitants)
- there are 3 distinct serelogic types of poliovirus (with no cross Immunity)
1) Type I – is the most paralytogenic or the most frequent cause of Paralytic poliomyelitis, both epidemic and
endemic.
2) Type II – the next most frequent.
3) Type III – the least frequently associated with paralytic disease.
Types of Poliomyelitis
1) Spinal
Ø Cervical
Ø Thoracic
Ø Lumbar
2) Bulbar
Ø Cranial nerves
Ø Circular System
Ø Respiratory System
3) Bulbo-spinal
4) Polioencephalitis
PERIOD OF COMMUNICABILITY:
Most contagious a few days before and after the onset of symptom when the virus is found
in the oropharynx for about a week, and in large quantities in the small bowel, and
continues to be in feces up to about 3 months.
Modes of Transmission:
- virus is harbored in GIT and is transmitted through saliva, vomitus and feces
1) Direct contact – from one person to another person through healthy carriers via the
intestinal/oral pathways.
- it has been shown that poliovirus excretors are much more commonly found
among householdor family contacts than among noncontact.
2) Indirect contact – fecal-oral through food, water, utensils and objects contaminated by
human exreta.
- occasionally, the virus may be implanted through the oropharynx and in very rare
instances by parenteral.
INCUBATION PERIOD:
- Usually 7-14 days, with a range of 5-35 days, for paralytic and non-paralytic forms; 3-5
days for the minor illness.

PATHOGENESIS:
- polio virus reaches the intestinal tract through the mouth, enters the intestinal mucosa and
lodges and multiplies in undetermined sites, possibly reticuloendothelial system. This is
known as the Intestinal Phase.
- The organism may then reach the blood (viremic phase) and then proceed to CSN (neural
phase)
- In each of these stages the body defences respond and resist the invading organisms.
- The disease may stop in any of this sites, depending on the promptness and effectiveness
of the host’s antibody response at that particular phase.
- Thus if the virus is inhibited or is stopped from increasing at the intestinal phase, adequate
immunity develops locally in the intestine as well as systematically, with hardly any clinical
manifestations. This is what happens in the asymptomatic, silent or subclinical
manifestations. This is also the principle of oral vaccination.
- If the virus proceeds unabated, it enters blood stream resulting in systemic manifestations
which, depending on the severity of infection may present dregs of fever, headache,
vomiting, and irritability.
- The milder manifestations constitute the Abortive type of the disease and the more severe
manifestations; the Meningitic or preparalytic Type.
- Unchecked, the organism proceed via nerve pathways to the CNS and again depending
on the site they invade, manifestations may correspondingly be Spinal, Bulbospinal or
Encephalit
CLINICAL MANIFESTATIONS:
4 Clinical forms are described:
1) Inapparent/Subclinical/Asymptomatic/Silent Type
- person who are expose to poliomyelitis ward like the nurses and other members of the
health team. But not all polio victim has small leg or both.
2) Abortive Type/Minor Illness of Poliomyelitis:
- starts with a mild to moderate upper respiratory infection or with symptoms of mild
influenza like slight fever, malaise, headache, sore throat, inflamed pharynx and vomiting.
This is follows by a remission of 1-2 days at which time the child may be active and playful.
- This case may be unnoticed.
3) Preparalytic or Meningitic Type/Major Illness of Poliomyelitis:
- then the second febrile stage is observe, this time with higher temperature, headache,
vomiting, restlessness, anorexia, lethargy and pain in the neck and back, arms, legs, and
abdomen.
- It cause also muscle spasms and tenderness in the extension or extensora of neck and
back.
- Is usually lasts about a week with meningeal irritation persisting for about 2 weeks.
4) Paralytic Type
- early manifestations are pain and some degree of stiffness followed by twitching and
diminished deep tendon reflexes.
- There may be hyperesthesia and irritability.
- Loss of tendon reflexes, positive Kernig’s Sign and Brudzinski’s Sign
- In one or two days later, weakening of muscle plus paralysis.
- Positive Hoyne’s Signs- his head will fall back when he is in supine and his shoulders are
elevated. He won’t be able to raise his legs at full 90 degrees.
DIAGNOSIS:
1. Isolation of the Virus
1. Blood- end of first week; WBC may be normal or slightly increased
2. Throat- end of first week until second week
3. Fecal/Stool- first week until third week
2. With CNS, CSF examination
a.CHON- normal and moderately elevated as disease progress
b. Sugar/Glucose content is normal

TREATMENT:
1. Abortive Type/Minor Illness
Ø Bed rest
Ø Analgesic-to ease headache, back pains and muscle spasm

2. Preparalytic or Meningitic Type/Major Illness

Ø Moist hot packs for 15-30 min every 2-4 hrs over the affected muscles
Ø Anxiety and fear should be allayed
Ø The limb should be in a position of comfort
3. Paralytic Type ( hospitalization required)
Ø Suitable body alignment; feet at the right angle, knees slightly flexed, hips and spine
straight, with the use of board, sand bags, and occasionally light splint shells
Ø Active and passive movements as soon as pain disappears
Ø Avoid fecal impaction
Ø Maintain good body alignment by using boards, sand bags, etc.
Ø Make bed with cotton or woollen blanket both under and over the pt.
Ø Change position frequently
Ø Daily bath if necessary and change wet clothes

4. To avoid spread of microorganism

Ø Secretions should be properly disposed
Ø Avoid contact with person having known cases
Ø Nasal and oral hygiene

PREVENTION:
1. Administration of polio vaccine
a. Salk Vaccine- solution of killed viruses that given intramuscularly
b. Sabin Vaccine- which is preparation attenuated living viruses that is administered orally.

2. Effective Immunization-programs may be achieved carried out community wide to include

all infants over 2 months old, children and young adults with the preschool age group as
priority target.
COMPLICATION
1. Respiratory paralysis- which includes the diaphragm and the inter costal muscle
2. Pneumonia
3. Myocarditis
4. Atelectasis
5. Pulmonary edema
6. Acute gastric dilatation, melena
7. Hypertension
8. Renal calculi
9. Late complication- skeletal and soft tissue deformity
DIAGNOSIS
1) ISOLATION OF THE VIRUS
a) Blood- by the end of the 1st week, WBC count may be normal or slightly increased.
b) Throat- by the end of the 1st week until the 2nd week
c) Fecal/stool- by the end of the 1st week until the 3rd or throughout the disease and even up
o 3 months.
d) CSF- is not a path gnomonic but may be help when considered with other manifestations
and the course of the disease.

2) SEROLOGIC DIAGNOSIS
- is of value when there is at least a 4 rise of antibody titer from the acute to the acute to the
convalescent stage, as determined by neutralization or complement fixation tests.
3) WITH CNS INVOLVEMENT, CSF EXAMINATION:
a) Pleocytosis with early predominance of polymorph nuclear cells followed by a shift to
mononuclear cells.
b) Proteins- normal in the early stage of the disease and may be moderate elevated as
disease progresses
c) Glucose/sugar content is normal.

PROGNOSIS
- recovery from the nonparalytic form of poliomyelitis is usually complete.
- In paralytic poliomyelitis, the degree of disability that results depends on the extent of
involvement and the management.
- Recovery of muscle function usually occurs spontaneously within a few weeks.
- Muscles which are paralyzed in 1 month after the onset of illness recover completely only
in less than 2% of the cases.
- Over all mortality for the paralytic form is about 4%
- Prognosis is poorer in order children and adults.
- Bulbar poliomyelitis is always serious particularly when the medulla and respiratory
muscles are involved.
PREVENTION
1. Administration of polio vaccine
1. Salk Vaccine- solution of killed viruses that given intramuscularly.
2. Sabin Vaccine- which is a preparation attenuated living viruses that is
administered orally:
Examples: Live Attenuated Trivalent Vaccine or Trivalent Oral Polio/Virus Vaccine (TOPV).
- immunity confers long lasting
- A booster dose after a year is recommended in low socioecomomic areas where the high
incidence of other enteroviruses may cause interference of immunity.

2. Effective Immunization
- Programs may be achieve if carried out community wide to include all infants over 2
months old, children and young adult with that preschool age group as priority target.

Special cansiderations of Poliomyelitis:

 Observe the patient carefully for signs of paralysis and other

neurologic damage, which can occur rapidly. Maintain a patent
airway, and watch for respiratory weakness and difficulty in
swallowing. A tracheotomy is commonly done at the first sign of
respiratory distress, after which the patient is placed on a
mechanical ventilator. Remember to reassure the patient that his
breathing is being supported. Practice strict aseptic technique
during suctioning, and use only sterile solutions to nebulize
medications.
 Perform a brief neurologic assessment at least once a day, but don't
demand any vigorous muscle activity. Encourage a return to mild
activity as soon as the patient is able.

 Check blood pressure frequently, especially in bulbar poliomyelitis,

which can cause hypertension or shock because of its effect on the
brain stem.

 Watch for signs of fecal impaction (due to dehydration and

intestinal inactivity). To prevent this, give sufficient fluids to ensure
an adequate daily output of low specific-gravity urine (1.5 to 2
L/day for adults).

 Monitor the bedridden patient's food intake for an adequate, well-

balanced diet. If tube feedings are required, give liquid baby foods,
juices, lactose, and vitamins.

 To prevent pressure ulcers, provide good skin care, reposition the

patient often, and keep the bed dry. Remember, muscle paralysis
may cause bladder weakness or transient bladder paralysis.

 Apply high-top sneakers or use a footboard to prevent footdrop. To

alleviate discomfort, use foam rubber pads and sandbags, as
needed, and light splints, as ordered .

 To control the spread of poliomyelitis, wash your hands thoroughly

after contact with the patient, especially after contact with
 excretions. Instruct the ambulatory patient to do the same. (Only
hospital personnel who have been vaccinated against poliomyelitis
may have direct contact with the patient.)

 Provide emotional support to the patient and his family. Reassure

the nonparalytic patient that his chances for recovery are good.
Long-term support and encouragement are essential for maximum
rehabilitation.

 When caring for a paralytic patient, help set up an interdisciplinary

rehabilitation program. Such a program should include physical and
occupational therapists, physicians and, if necessary, a psychiatrist
to help manage the emotional problems that develop in a patient
suddenly facing severe physical disabilities.
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