|Year : 2013 | Volume
| Issue : 2 | Page : 103-105
Postdiphtheritic acute flaccid paralysis: An epidemiological investigation report
Namratha Kulkarni, Nikhil P Hawal, Vijaya A Naik, Umesh S Charantimath
Department of Community Medicine, Jawaharlal Nehru Medical College, Karnatak Lingayat Education University, Belgaum, Karnataka, India
|Date of Web Publication||23-Jul-2013|
Department of Community Medicine, Jawaharlal Nehru Medical College, Belgaum - 590 010, Karnataka
Source of Support: None, Conflict of Interest: None
A 10-year-old girl presented with faucial diphtheria, 2 weeks following which she presented with acute flaccid paralysis (AFP). The case was notified to the district polio surveillance officer and was epidemiologically investigated. Outer ring immunization was done and her stool samples were negative for wild polio. The case was thus labelled nonpolio AFP postdiphtheria.
Keywords: Acute flaccid paralysis, epidemiological investigation, outer ring immunization
|How to cite this article:|
Kulkarni N, Hawal NP, Naik VA, Charantimath US. Postdiphtheritic acute flaccid paralysis: An epidemiological investigation report. J Sci Soc 2013;40:103-5
|How to cite this URL:|
Kulkarni N, Hawal NP, Naik VA, Charantimath US. Postdiphtheritic acute flaccid paralysis: An epidemiological investigation report. J Sci Soc [serial online] 2013 [cited 2019 Nov 12];40:103-5. Available from: http://www.jscisociety.com/text.asp?2013/40/2/103/115480
| Introduction|| |
In April 2003, Dr. Gro Harlem Bruntland, the Director General of WHO had expressed that in today's world, there is simply no moral or economic justification for any child anywhere in the world to be crippled by polio.
"There is no cure for polio, it can only be prevented." As the saying goes, the main defence against poliomyelitis is the prophylactic immunization and the public health measure plays a very small and subsidiary role in prevention.  Poliomyelitis is a viral infection involving the anterior horn cells of the spinal cord. With the extensive use of effective vaccine, it has become increasingly rare in developed countries. 
In this era of eradication of polio, even a single case is treated as an outbreak and preventive measures should be initiated, usually within 48 h of notification. Currently, the polio eradication initiative is at such a stage that requires timely and complete reporting of cases of acute flaccid paralysis (AFP), collect the stool sample within 14 days and conduct an outbreak response immunisation (ORI) as early as possible. 
Here, we report one case of AFP which was epidemiologically investigated as per Ministry of Health and Family Welfare and WHO Guidelines and ORI was conducted in the community. 
| Case Report|| |
A 10-year-old girl residing at Ukkad village coming under the Primary health centre (PHC) Vantmuri attached to the Department of Community Medicine of J. N. Medical College, Belgaum was brought to the District Hospital, Belgaum with the history of acute onset of fever of high degree, associated with cough with expectoration since 1 week. She also had severe headache and one episode of generalized tonic-clonic convulsions.
On examination, the girl was drowsy and was not oriented to time, place, and person. She had tachycardia, tachypnea, and reactive pupils. Her blood pressure could not be recorded. She had bilaterally decreased air entry and rhonchi on respiratory system examination. Neurologically, the patient had developed weak gag reflex and facial palsy, followed by loss of superficial reflexes and then deep reflexes. Within a week, she developed right-sided hemiplegia which was gradual.
History revealed that she was admitted in KLE's Dr. Prabhakar Kore Charitable Hospital for 2 weeks for the history of fever, throat pain, swelling of neck, and odynophagia. Her throat swab culture was positive for Corynebacterium diphtheriae and was treated with antidiphtheritic serum and antibiotics for faucial diphtheria. On discharge, she was administered Diphtheria-Tetanus toxoid (DT) vaccine.
| Laboratory Investigations|| |
Random blood glucose when she was brought to the hospital was 57 mg/dL. Her other lab reports were as follows:
Cerebrospinal fluid (CSF) analysis showed
- Hemoglobin: 13.4 gm%
- Total leukocyte count: 9300 cells/mm 3 (neutrophils: 75%, lymphocytes: 21%, eosinophils: 02%, monocytes: 02%)
- Platelet count: 3.36 lacs/mm 3 and ESR (Erythrocyte Sedimentation Rate) of 80 mm at the end of 1 h
- Serum electrolytes: Sodium-132.7 meq/L and potassium 3.0 meq/L.
Cell count: 04 cells/mm 3 with 98% lymphocytes and 02% neutrophils.
CSF sugars: 68.7 mg/dL and proteins-126 mg/dL.
She was treated with antibiotics, steroids, intravenous fluids and other essential drugs. After about 15 days of treatment in the District hospital, the patient got discharged against the medical advice.
On epidemiological investigation, it was revealed that the girl had not taken any routine immunization except for a few irregular doses of polio vaccine during pulse polio programs. She had no travel history for the past 1 month. The case was notified to the District Health and Family Welfare Officer and the Surveillance Medical Officer, NPSP, Belgaum. The girl did not pass stools with in 14 days of the onset of paralysis. Two stool samples 24 h apart were collected on 20 th and 23 rd days. The stool samples were sent to the National Institute of Virology (NIV), Bangalore in reverse cold chain for detection of wild polio virus.
An ORI was planned on 5 th day following the reporting of the case and 92 children of 0-5 years age-group were administered Oral Polio Vaccine (OPV) doses by the field staff of the PHC, Vantmuri. A house to house active search of cases was conducted to ensure there were no more similar cases in the community. The parents managed the patient by complete bed rest, hot water fomentation, symptomatic treatment, and physiotherapy. The NIV report for wild polio virus was negative and the patient improved significantly in the next 2 months. Based on the history and lab reports, the case was diagnosed as postdiphtheritic paralysis and was labelled "Nonpolio acute flaccid paralysis."
| Discussion|| |
Only 1 out of 200 infections with polio virus results in clinically apparent paralytic disease. To ensure that no cases of polio are missed, all cases of AFP are reported and investigated The nonpolio AFP rate over time in each geographic area helps to assess the sensitivity of the surveillance system. 
AFP surveillance depends on the following main system elements:
AFP is the lower motor neuron lesion characterized by acute onset of weakness with reduced muscular tone in a previously normal limb, usually below 15 years of age.  The most frequent cause of AFP that must be distinguished from poliomyelitis is the Guillain-Barre syndrome. The other important causes of AFP include transverse myelitis, traumatic neuritis, enteroviral encephalopathy, cerebral palsy, nonspecific viral infections, malnutrition, infectious, and toxic neuropathies like diphtheritic paralysis, and so on.
- Immediate reporting and investigation of AFP cases
- Routine monthly negative reporting ("zero" reporting even if no AFP case is seen) from all the health facilities
- Weekly active surveillance visits to priority health facilities and other reporting sites likely to see AFP cases. 
Diphtheria is an acute toxic infection caused by Corynebacterium diphtheriae is an exclusive inhabitant of human mucous membranes and skin. Incidence peaks during autumn and winter and majority of cases occur in unimmunized children below 15 years of age. Toxin is distributed via blood stream and lymphatics throughout the body. Any organ or tissue can be damaged as a result of diphtheria toxin, but lesions of the heart, nervous system, and kidneys are particularly prominent. Clinical manifestations appear after a latent period ranging from 10 to 14 days for myocarditis and from 3 to 7 weeks for nervous system manifestations such as peripheral neuritis. Antitoxin can neutralize circulating toxin or toxin that is absorbed to cells but is ineffective once cell penetration has occurred. Thus, early treatment is essential to limiting tissue damage.
The signs and symptoms of diphtheria will depend upon the site of infection, the immunization status of the host, and whether or not toxin has been distributed to the systemic circulation. Neurologic complications appear after a variable latent period, are predominantly bilateral, are motor rather than sensory, and usually resolve completely. Paralysis of the soft palate is common and generally appears in the 3 rd week. 
India appears to have interrupted wild poliovirus transmission, completing 2 year without polio since its last case, in a 2-year-old girl in the state of West Bengal, on 13 January 2011.  There has been a steady declining trend in the number of AFP cases that are being reported every year. A total of 31 cases have been reported in Belgaum as per 36 th week report of the year [Figure 1].
In conclusion, intensive surveillance is essential to reach the goal of polio eradication in this subcontinent. It is important to maintain vigilance on the importation of wild poliovirus. It is crucial to sustain high polio immunization coverage among the local population and to monitor laboratory inventories for wild poliovirus. Constant support in notifying AFP cases promptly is essential for a successful AFP surveillance. Continuous commitment of the health sector is vital to the certification of eradication of poliomyelitis.
| Acknowledgments|| |
- Principal, JNMC and Medical Superintendent, KLES Dr. Prabhakar Kore Hospital and M. R. C., Belgaum
- District Surgeon, Belgaum
- Dr. Aniruddha Deshpande Surveillance Medical Officer, NPSP, Belgaum
- Dr. Shivaswamy M S., M.D. (Community Medicine), Professor, Community Medicine, J. N. Medical College, Belgaum.
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