Poliomyelitis - the viral infection proceeding with primary damage of the central nervous system (gray substance of a spinal cord) and leading to development of sluggish paresis and paralyzes. Depending on a clinical form the course of poliomyelitis can be as malosimptomny (with short-term fever, the catarrhal phenomena, dyspepsia), and with the expressed meningealny symptoms, vegetative frustration, development of peripheral paralyzes, deformations of extremities etc. Diagnosis of poliomyelitis is based on allocation of a virus in biological liquids, results of RSK and IFA-diagnostics. Treatment of poliomyelitis includes symptomatic therapy, vitamin therapy, physiotreatment, LFK and massage.
Poliomyelitis (Heine-Medina's disease, children's spinal paralysis) - the enteroviral infection caused by the polioviruses affecting motor-neurons of forward horns of a spinal cord that leads to heavy paralytic complications with the patient's invalidization. The greatest susceptibility to poliomyelitis (60-80%) is noted at children aged to 4 years therefore the disease is studied, mainly, within pediatrics, children's neurology and children's orthopedics.
The last epidemic of poliomyelitis in Europe and North America was recorded in the middle of last century. In 1988 WHO was adopted the resolution which proclaimed a problem of elimination of poliomyelitis in the world. Now in the territory of the countries where preventive vaccination against poliomyelitis is carried out, the disease meets in the form of isolated, sporadic cases. Still endemic on poliomyelitis are Afghanistan, Nigeria, Pakistan, Syria, India. Countries of Western Europe, North America and Russia are considered as territories, free from poliomyelitis.
The infection is caused by three anti-gene types of the poliovirus (I, II and III) relating to a sort of enteroviruses, family of picornaviruses. The greatest danger is constituted by the virus of poliomyelitis of the I type causing 85% of all cases of a paralytic form of a disease. Being steady in the external environment, the virus of poliomyelitis can remain up to 100 days in water and up to 6 months - in excrements; it is good to transfer drying and freezing; it is not inactivated under the influence of digestive juice and antibiotics. Death of a poliovirus occurs during the heating and boiling, ultra-violet radiation, processing by disinfectants (chloric lime, chloroamine, formalin).
As infection source at poliomyelitis both the sick person, and the asymptomatic virus carrier allocating a virus with nasopharyngeal slime and excrements can act. Transfer of a disease can be carried out contact, airborne and fecal and oral in the ways. The susceptibility to a poliomyelitis virus in population makes 0,2–1%; the vast majority of the diseased is made by children up to 7 years. The seasonal peaks of incidence fall on the aestivo-autumnal period.
Vaktsino-assotsiirovanny poliomyelitis develops at the children with the immunodeficiency expressed congenital or acquired (is more often HIV infection) receiving a live oral attenuirovanny vaccine.
As the conditions promoting spread of a virus of poliomyelitis serve insufficient hygienic skills at children, bad sanitary and hygienic conditions, density of the population, lack of mass specific prevention.
As entrance gate for a poliomyelitis virus in an organism of the new owner serves limfoepitelialny fabric roto-and nasopharynxes, intestines where there is primary replication of the activator and from where it gets into blood. In most cases primary virusemiya lasts 5-7 days and at activation of immune system comes to an end with recovery. Only at 1-5% infected the secondary virusemiya with selective defeat of motor-neurons of forward horns of a spinal cord and a trunk of a brain develops. Penetration of a virus of poliomyelitis into nervous tissue happens not only through a hematoencephalic barrier, but also a perinevralny way.
Taking root into cages, the virus of poliomyelitis causes violation of synthesis of nucleinic acids and protein, leading to dystrophic and destructive changes up to full death of neuron. Destruction of 1/3-1/4 nervous cages leads to development of paresis and full paralyzes with the subsequent atrophy of muscles and contractures.
Classification of poliomyelitis
In clinical practice distinguish the poliomyelitis forms proceeding without defeat of nervous system and with defeat of TsNS. Forms concern to the first group inapparantny and abortive (visceral); to the second – not paralytic (meningealny) and paralytic forms of poliomyelitis.
Depending on the level of defeat of nervous system the paralytic form of poliomyelitis can be expressed in the following options:
- spinal of which sluggish paralyzes of extremities, necks, diaphragms, trunks are characteristic;
- bulbarny, followed by violations of the speech (a dizartriya, a dysphonia), swallowing, warm activity, breath;
- pontinny, proceeding with full or partial loss of a mimicry, lagoftalmy, svisaniy a mouth corner on one half of the face;
- entsefalitichesky with all-brain and focal symptoms;
- mixed (bulbospinalny, pontospinalny, bulbopontospinalny).
Separately such vaccine-challenged complication as vaktsinoassotsiirovanny paralytic poliomyelitis is considered. Frequency of development of paralytic and not paralytic forms of poliomyelitis makes 1:200.
During paralytic forms of poliomyelitis allocate the incubatory, preparalitichesky, paralytic, recovery and residual periods.
The incubatory period at various forms of poliomyelitis averages 8–12 days.
The Inapparantny form of poliomyelitis represents a virus carriage which is not shown clinically in any way and it can be revealed only in the laboratory way.
The abortive (visceral) form of poliomyelitis makes more than 80% of all cases of a disease. Clinical manifestations are not specific; among them all-infectious symptoms – fever, intoxication, a headache, the moderate catarrhal phenomena, belly-aches, diarrhea prevail. The disease comes to an end in 3-7 days with an absolute recovery; residual neurologic symptoms are not noted.
The Meningealny form of poliomyelitis proceeds as benign serous meningitis. At the same time two-wave fever, headaches, moderately expressed meningealny symptoms is noted (Brudzinsky, Kerniga, a rigidnost of occipital muscles). In 3-4 weeks there occurs recovery.
The paralytic form of poliomyelitis has the heaviest current and outcomes. In the preparalitichesky period the all-infectious symptomatology prevails: temperature increase, dyspepsia, rhinitis, pharyngitis, tracheitis, etc. The second wave of fever is followed by the meningealny phenomena, the mialgiya, backbone and extremities pains expressed by a giperesteziya, gipergidrozy, confusion of consciousness and spasms.
Approximately for 3-6 day the disease enters the paralytic phase which is characterized by sudden development of paresis and paralyzes is more often than the lower extremities at safe sensitivity. Asymmetry, unevenness, primary defeat of proximal departments of extremities are characteristic of paralyzes at poliomyelitis. Slightly less often at poliomyelitis paresis and paralyzes of the top extremities, persons, trunk muscles develop. In 10-14 days the first signs of a muscular atrophy are observed. Paralysis of respiratory muscles and a diaphragm can cause damage to the vital centers of a medulla and to serve as a cause of death of the child from sharp respiratory insufficiency.
In the recovery period of poliomyelitis which lasts till 1 year there is a gradual activization of tendinous reflexes, the movements in separate muscular groups are restored. Mosaicity of defeat and unevenness of restoration causes development of an atrophy and muscular contractures, lag of the affected extremity in growth, formation of osteoporosis and an atrophy of a bone tissue.
In the residual period the residual phenomena of poliomyelitis – persistent sluggish paralyzes, contractures, a paralytic clubfoot, shortening and deformations of extremities, valgusny deformation of feet, kifoskolioza and so forth are noted.
Diagnosis of poliomyelitis
Poliomyelitis at the child can be suspected by the pediatrician or the children's neurologist on the basis of the anamnesis, epidemiological data, diagnostic significant symptoms. In a preparalitichesky stage recognition of poliomyelitis is complicated in this connection the diagnosis of flu, OVRI, sharp intestinal infection, serous meningitis of other etiology mistakenly is established.
The major role in etiologichesky diagnosis of poliomyelitis is played by laboratory tests: allocation of a virus from slime of a nasopharynx, excrements; the IFA methods (IgM detection) and RSK (increase of a caption of virusospetsifichesky antibodies in pair serums). For differentiation of types of a virus of poliomyelitis PTsR is used.
When carrying out a lyumbalny puncture cerebrospinal fluid follows under elevated pressure; the research of tserebrospinalny liquid at poliomyelitis reveals its transparent, colourless character, moderate increase in concentration of protein and glucose. The electromyography confirms defeat at the level of forward horns of a spinal cord.
Treatment of poliomyelitis
Manifest forms of poliomyelitis are treated permanently. The general actions include isolation of the sick child, a bed rest, rest, a high-calorific diet. In the correct care of sick poliomyelitis an important role is played by giving to extremities of the correct (physiological) situation, prevention of decubituses, massage of a thorax. At a dysphagy food via the nazogastralny probe will be organized; at violation of independent breath IVL is carried out.
As specific treatment of poliomyelitis is not developed, mainly, symptomatic and pathogenetic therapy is carried out. Group B vitamins, ascorbic acid, anesthetics and dehydrating medicines, a neostigmina, respiratory analeptik, etc. are appointed.
In the recovery period the main role in complex therapy of poliomyelitis is assigned to rehabilitation actions: LFK, to orthopedic massage, parafinolecheniye, UVCh, elektromiostimulyation, general medical bathtubs, sanatorium treatment.
Treatment of poliomyelitis is carried out with the assistance of the children's orthopedist. For prevention of development of contractures imposing of plaster bandages, steak, orthopedic tires, wearing orthopedic footwear can be shown. Ortopedo-hirurgichesky treatment of the residual phenomena of poliomyelitis can include a tenomiotomiya and tendinous and muscular plasticity, , and joints, a resection and an osteotomiya of bones, surgical correction of scoliosis and so forth.
Forecast and prevention of poliomyelitis
The easy forms of poliomyelitis (proceeding without defeat of TsNS and meningealny) pass completely. Severe paralytic forms can lead to a resistant invalidization and a lethal outcome. Thanks to long-term purposeful vaccinal prevention of poliomyelitis in structure of a disease lungs inapparantny and abortive forms of an infection prevail; paralytic forms arise only at not vaccinated persons.
Prevention of poliomyelitis includes obligatory planned vaccination and a revaccination of all children according to a national calendar of inoculations. Children with suspicion of poliomyelitis are subject to immediate isolation; disinfection is indoors carried out; contact persons are subject to observation and extraordinary immunization of OPV.