Acute flaccid paralysis in children and adults. Acute flaccid paralysis

Poliomyelitis (infantile paralysis)) is caused by a virus and is a highly contagious viral infection. In its most serious form, polio can cause rapid and irreversible paralysis; until the end of the 1950s, it was one of the most dangerous infectious diseases and often occurred in the form of epidemics. Post-polio syndrome or post-polio progressive muscle atrophy can occur 30 years or more after the initial infection, gradually leading to muscle weakness, atrophy, and pain. Polio can be prevented by building up immunity, and has now virtually disappeared in developed countries; however, the risk of disease still exists. Polio is still common in many parts of the world and there is no way to cure it; therefore, until the polio virus is eradicated, vaccination remains the main form of protection.

In summer and early autumn, when polio epidemics are most common, parents first of all remember about it when a child falls ill. The disease, like many other infections, begins with general malaise, fever and headache. Vomiting, constipation, or mild diarrhea may occur. But even if your child has all these symptoms, plus leg pain, don't jump to conclusions. Chances are still high that it's the flu or a sore throat. Of course, in any case, you call a doctor. If he is gone for a long time, you can calm down this way: if the child can lower his head between his knees or tilt his head forward so that his chin touches his chest, he probably does not have polio. (But even if he fails these tests, it is still not proof of illness.)
Despite significant progress in the eradication of poliomyelitis in our country, the problem of diseases accompanied by acute flaccid paralysis (AFP) has not lost its relevance. Pediatricians often have to deal with various infectious diseases of the brain and spinal cord, peripheral nerves. The study of the structure of neuroinfections indicates that lesions of the peripheral nervous system occur in 9.6% of patients, infectious diseases of the spinal cord - in 17.7%. Among the latter, acute infectious myelopathy predominates, while acute paralytic vaccine-associated poliomyelitis, acute myelopathy, and enceare much less common. In this regard, in modern conditions, it is necessary to pay special attention to the differential diagnosis of AFP, monitoring the epidemic situation, which will avoid overdiagnosis, improve treatment results, and reduce the frequency of unjustified registration. post-vaccination complications.

Acute paralytic poliomyelitis - group viral diseases combined according to the topical principle, characterized by flaccid paresis, paralysis caused by damage to motor cells in the anterior horns of the spinal cord and the nuclei of the motor cranial nerves of the brain stem.

Etiology. The etiological structure of infectious diseases of the nervous system is diverse. Among the etiological factors are “wild” polioviruses 1, 2, 3rd type, vaccine polioviruses, enteroviruses (ECHO, Coxsackie), herpesviruses (HSV, HHV type 3, EBV), influenza virus, mumps virus, diphtheria bacillus, borrelia, UPF (staphylococci, gram-negative bacteria).

Of particular interest is spinal paralysis caused by the "wild" poliomyelitis virus, belonging to the picornavirus family, the genus Enterovirus. The causative agent is small (18-30 nm), contains RNA. Synthesis of the virus and its maturation occur inside the cell.

Polioviruses are not sensitive to antibiotics and chemotherapy drugs. When frozen, their activity persists for several years, in a household refrigerator for several weeks, and at room temperature for several days. At the same time, poliomyelitis viruses are quickly inactivated when treated with formaldehyde, free residual chlorine, they do not tolerate drying, heating, and ultraviolet radiation.

The polio virus has three serotypes - 1, 2, 3. Its cultivation in the laboratory is carried out by infecting various tissue cultures and laboratory animals.

The reasons

Poliomyelitis is caused by a viral infection with one of three forms of the polio virus.

The virus can be transmitted through contaminated food and water, or through infected saliva during coughing or sneezing.

The source of infection is a sick person or a carrier. The greatest epidemiological significance is the presence of the virus in the nasopharynx and intestines, from where it is released into the external environment. In this case, the isolation of the virus with feces can last from several weeks to several months. The causative agent of poliomyelitis is contained in the nasopharyngeal mucus for 1-2 weeks.

The main routes of transmission are alimentary and airborne.

In a mass specific prevention sporadic cases have been reported throughout the year. Mostly children under the age of seven were ill, of which specific gravity early age patients reached 94%. The contagiousness index is 0.2-1%. Mortality in the unvaccinated reached 2.7%.

The World Health Organization in 1988 raised the issue of the complete eradication of poliomyelitis caused by the "wild" virus. In this regard, 4 main strategies have been adopted to combat this infection:

1) achieving and maintaining a high level of population coverage with preventive vaccinations;

2) providing additional vaccinations on national immunization days (NIDs);

3) creation and functioning of an effective system of epidemiological surveillance for all cases of acute flaccid paralysis (AFP) in children under 15 years of age with mandatory virological examination;

4) carrying out additional "cleaning up" immunization in disadvantaged areas.

At the time of the adoption of the Global Polio Eradication Program, the number of patients in the world was 350,000. However, by 2003, thanks to ongoing activities, their number had dropped to 784. Three regions of the world are already free from polio: America (since 1994), Western Pacific (since 2000) and European (since 2002). However, in the Eastern Mediterranean, African regions and South-East Asia Poliomyelitis caused by wild poliovirus continues to be reported. India, Pakistan, Afghanistan, Nigeria are considered endemic for poliomyelitis.

Since December 2009, an outbreak of poliomyelitis caused by type 1 poliovirus has been recorded in Tajikistan. It is assumed that the virus came to Tajikistan from neighboring countries - Afghanistan, Pakistan. Taking into account the intensity of migration flows from the Republic of Tajikistan to the Russian Federation, including labor migration and active trade relations, the “wild” polio virus was imported into the territory of our country, cases of poliomyelitis were registered in adults and children.

Russia launched the Global Program for the Eradication of Poliomyelitis on its territory in 1996. Thanks to the maintenance of a high level of vaccination coverage for children of the first year of life (more than 90%), the improvement of epidemiological surveillance, the incidence of this infection in Russia has decreased from 153 cases in 1995 to up to 1 - in 1997. By decision of the European Regional Certification Commission in 2002. Russian Federation has been declared a polio-free area.

Before switching to use inactivated vaccine against poliomyelitis in Russia, diseases caused by vaccine polioviruses (1-11 cases per year) were registered, as a rule, on the introduction of the first dose of live OPV.

Diagnostics

Medical history and physical examination.

Blood tests.

Lumbar puncture (spinal tap).

Laboratory diagnostics. Only based on the results of virological and serological studies, it is possible to establish the final diagnosis of poliomyelitis.

Virological testing for poliomyelitis in the laboratories of regional centers for epidemiological surveillance of poliomyelitis/ AFP is subject to:

- sick children under 15 years of age with symptoms of acute flaccid paralysis;

— contact children and adults from the foci of poliomyelitis and AFP in the case of late (later than the 14th day from the moment of detection of paralysis) examination of the patient, as well as in the presence of persons around the patient who arrived from territories unfavorable for poliomyelitis, refugees and forced migrants (once) ;

— children under the age of 5 who arrived within the last 1.5 months from the Chechen Republic, the Republic of Ingushetia and applied for medical care to medical institutions, regardless of the profile (once).

Patients with clinical signs poliomyelitis or acute flaccid paralysis are subject to a mandatory 2-fold virological examination. The first sample of faeces is taken within a day from the moment of diagnosis, the second sample - after 24-48 hours. The optimal volume of faeces is 8-10 g. The sample is placed in a sterile special plastic container. If samples are delivered to the Regional Polio/AFP Surveillance Center within 72 hours of collection, the samples are refrigerated at 0 to 8°C and transported to the laboratory at 4 to 8°C (reverse cold). chain). In cases where the delivery of the material to the virological laboratory is planned to be carried out in more late dates samples are frozen at -20°C and transported frozen.

The frequency of virus isolation in the first two weeks is 80%, on the 5-6th week - 25%. No permanent carrier has been identified. From the cerebrospinal fluid, unlike the Coxsackie and ECHO viruses, the polio virus is extremely rare.

In case of lethal outcomes, the material is taken from the cervical and lumbar extensions of the spinal cord, cerebellum and contents colon. With paralysis lasting 4-5 days, it is difficult to isolate the virus from the spinal cord.

Serological examination is subject to:

- Patients with suspected poliomyelitis;

- children under the age of 5 who arrived within the last 1.5 months from the Chechen Republic, the Republic of Ingushetia and applied for medical care to medical institutions, regardless of their profile (once).

For serological study take two samples of the patient's blood (5 ml each). The first sample should be taken on the day of the initial diagnosis, the second - after 2-3 weeks. Blood is stored and transported at a temperature of 0 to +8 °C.

RSK detects complement-fixing antibodies to N- and H-antigens of poliovirus. In the early stages, only antibodies to the H-antigen are detected, after 1-2 weeks - to H- and N-antigens, in those who have been ill - only N-antibodies.

During the first infection with poliovirus, strictly type-specific complement-fixing antibodies are formed. Upon subsequent infection with other types of polioviruses, antibodies are formed mainly to thermostable group antigens, which are present in all types of polioviruses.

PH detects virus-neutralizing antibodies in the early stages of the disease, it is possible to detect them at the stage of hospitalization of the patient. Virus-neutralizing antibodies can be detected in the urine.

RP in agar gel reveals precipitins. Type-specific precipitating antibodies can be detected during the recovery period, circulate for a long time. To confirm the increase in antibody titers, paired sera are examined at intervals of 3-4 weeks; a serum dilution that exceeds the previous one by 3-4 times or more is taken as a diagnostic increase. The most effective method is ELISA, which allows short time determine the class-specific immune response. It is mandatory to carry out PCR in order to detect RNA viruses in individual feces, cerebrospinal fluid.

Symptoms

Fever.

Headache and sore throat.

Fixed neck and back.

Nausea and vomiting.

Muscle pain, weakness, or spasms.

Difficulty in swallowing.

Constipation and retention of urine.

Bloated belly.

Irritability.

extreme symptoms; muscle paralysis; difficulty breathing.

Pathogenesis. The entry gates of infection in poliomyelitis are the mucous membrane of the gastrointestinal tract and upper respiratory tract. The reproduction of the virus occurs in the lymphatic formations of the posterior wall of the pharynx and intestines.

Overcoming the lymphatic barrier, the virus enters the bloodstream and spreads throughout the body with its current. Fixation and reproduction of the causative agent of poliomyelitis occurs in many organs and tissues - lymph nodes, spleen, liver, lungs, heart muscle and, especially, in brown fat, which is a kind of virus depot.

Penetration of the virus into the nervous system is possible through the endothelium of small vessels or along peripheral nerves. Distribution within the nervous system occurs along the dendrites of cells and, possibly, through intercellular spaces. When the virus interacts with the cells of the nervous system, the most profound changes develop in motor neurons. The synthesis of polioviruses occurs in the cytoplasm of the cell and is accompanied by suppression of the synthesis of DNA, RNA and proteins of the host cell. The latter dies. Within 1-2 days, the virus titer in the central nervous system increases, and then begins to fall, and soon the virus disappears.

Depending on the state of the macroorganism, properties and dose of the pathogen pathological process can stop at any stage of viral aggression. At the same time, various clinical forms of poliomyelitis are formed. In most infected children, due to the active reaction of the immune system, the virus is eliminated from the body and recovery occurs. Thus, in the inapparent form, the alimentary phase of development takes place without viremia and invasion into the CNS, while in the abortive form, the alimentary and hematogenous phases take place. For clinical options, accompanied by damage to the nervous system, is characterized by the consistent development of all phases with damage to motor neurons at different levels.

Pathomorphology. Morphologically, acute poliomyelitis is most characterized by damage to large motor cells located in the anterior horns of the spinal cord and the nuclei of the motor cranial nerves in the brain stem. In addition, the motor area of ​​the cerebral cortex, the nuclei of the hypothalamus, and the reticular formation may be involved in the pathological process. In parallel with the damage to the spinal cord and brain, the meninges are involved in the pathological process, in which acute inflammation develops. At the same time, the number of lymphocytes and protein content in the cerebrospinal fluid increase.

Macroscopically, the spinal cord looks edematous, the border between the gray and white matter is blurred, in severe cases, gray matter retraction is noted on the transverse section.

Microscopically, in addition to swollen or completely disintegrated cells, there are unchanged neurons. This "mosaic" of nerve cell damage is clinically manifested by an asymmetric, random distribution of paresis and paralysis. At the site of dead neurons, neuronophagic nodules are formed, followed by proliferation of glial tissue.

Classification

According to modern requirements standard definition poliomyelitis and acute flaccid paralysis (AFP) is based on the results of clinical and virological diagnostics (Appendix 4 to the order of the Ministry of Health of the Russian Federation No. 24 of 01/25/99) and is presented as follows:

- acute flaccid spinal paralysis, in which the "wild" polio virus is isolated, is classified as acute paralytic poliomyelitis (according to ICD 10 revision A.80.1, A.80.2);

- acute flaccid spinal paralysis, which occurred no earlier than the 4th and no later than the 30th day after receiving a live polio vaccine, in which the vaccine-derived polio virus was isolated, is classified as acute paralytic poliomyelitis associated with the vaccine in the recipient (according to ICD 10 revision A .80.0);

- acute flaccid spinal paralysis that occurred no later than the 60th day after contact with a vaccinated person, in which vaccine-derived poliovirus was isolated, is classified as acute paralytic poliomyelitis associated with a vaccine in a contact (according to ICD 10 revision A.80.0). Isolation of vaccine-derived poliomyelitis virus in the absence of clinical manifestations does not have diagnostic value;

- acute flaccid spinal paralysis, in which the examination was not carried out completely (the virus was not isolated) or was not carried out at all, but residual flaccid paralysis is observed by the 60th day from the moment of their occurrence, is classified as acute paralytic poliomyelitis, unspecified (according to ICD 10 revision A .80.3);

- acute flaccid spinal paralysis, in which a complete adequate examination was carried out, but the virus was not isolated and no diagnostic increase in antibodies was obtained, is classified as acute paralytic poliomyelitis of another, non-polio etiology (according to ICD 10, revision A.80.3).

The isolation of a "wild" strain of the virus from a patient with catarrhal, diarrheal or meningeal syndromes without the occurrence of flaccid paresis or paralysis is classified as acute non-paralytic poliomyelitis (A.80.4.)

Acute flaccid spinal paralysis with the release of other neurotropic viruses (ECHO, Coxsackie, herpesviruses) refers to diseases of a different, non-polio etiology.

All these diseases, based on the topical principle (lesion of the anterior horns of the spinal cord), appear under the general name "Acute poliomyelitis".

Polio classification

According to the severity of the process, mild, moderate and severe forms of poliomyelitis are distinguished. The course of the disease is always acute, and the nature can be smooth or uneven, depending on the presence of complications (osteoporosis, fractures, urolithiasis, contracture, pneumonia, bedsores, asphyxia, etc.).

Clinic. Duration incubation period with poliomyelitis is 5-35 days.

The spinal form of poliomyelitis in children is more common than other paralytic forms. In this case, more often the pathological process develops at the level of the lumbar enlargement of the spinal cord.

During the course of the disease, several periods are distinguished, each of which has its own characteristics.

The preparalytic period is characterized by an acute onset of the disease, deterioration of the general condition, an increase in body temperature to febrile numbers, headache, vomiting, lethargy, adynamia, and meningeal signs. General infectious, cerebral and meningeal syndromes can be combined with catarrhal or dyspeptic symptoms. In addition, there are positive symptoms of tension, complaints of pain in the back, neck, limbs, pain on palpation of the nerve trunks, fasciculations and horizontal nystagmus. The duration of the preparalytic period is from 1 to 6 days.

The paralytic period is marked by the appearance of flaccid paralysis or paresis of the muscles of the limbs and trunk. support diagnostic features this stage are:

- sluggish nature of paralysis and their sudden appearance;

- a rapid increase in movement disorders for a short time (1-2 days);

- damage to the proximal muscle groups;

- asymmetric nature of paralysis or paresis;

- absence of violations of sensitivity and function of the pelvic organs.

At this time, changes in the cerebrospinal fluid occur in 80-90% of patients with poliomyelitis and indicate the development of serous inflammation in the meninges. With the development of the paralytic stage, the general infectious symptoms fade away. Depending on the number of affected segments of the spinal cord, the spinal form may be limited (monoparesis) or widespread. The most severe forms are accompanied by a violation of the innervation of the respiratory muscles.

The recovery period is accompanied by the appearance of the first voluntary movements in the affected muscles and begins on the 7-10th day after the onset of paralysis. With the death of 3/4 of the neurons responsible for the innervation of any muscle group, the lost functions are not restored. Over time, atrophy increases in these muscles, contractures, ankylosis of the joints, osteoporosis, and limb growth lag appear. The recovery period is especially active during the first months of the disease, then it slows down somewhat, but lasts for 1-2 years.

If after 2 years the lost functions are not restored, then they speak of a period of residual phenomena ( various deformations, contractures, etc.).

The bulbar form of poliomyelitis is characterized by damage to the nuclei of 9, 10, 12 pairs of cranial nerves and is one of the most dangerous variants of the disease. In this case, there is a disorder of swallowing, phonation, pathological secretion of mucus in the upper respiratory tract. Of particular danger is the localization of the process in the medulla oblongata, when, due to the defeat of the respiratory and cardiovascular centers, there is a threat to the life of the patient. Harbingers of an unfavorable outcome in this case are the occurrence of pathological respiration, cyanosis, hyperthermia, collapse, impaired consciousness. The defeat of 3, 4, 6 pairs of cranial nerves in polio is possible, but less common.

The pontine form of poliomyelitis is the most mild, but cosmetic defect may remain with the child for life. Clinical characteristics This form of the disease is the defeat of the nucleus of the facial nerve. At the same time, immobility of the mimic muscles on the affected side suddenly occurs and lagophthalmos, Bell's symptoms, "sails", pulling the corner of the mouth to the healthy side while smiling or crying appear. The pontine form of poliomyelitis more often than others occurs without fever, general infectious symptoms, and changes in the cerebrospinal fluid.

The meningeal form of poliomyelitis is accompanied by lesions of the pia mater. The disease begins acutely and is accompanied by a deterioration in the general condition, an increase in body temperature to febrile numbers, headache, vomiting, lethargy, weakness, meningeal signs.

Symptoms characteristic of the meningeal form of poliomyelitis are pain in the back, neck, limbs, positive symptoms of tension, pain on palpation of the nerve trunks. In addition, fasciculations and horizontal nystagmus may be seen. An electromyogram revealed a subclinical lesion of the anterior horns of the spinal cord.

During a lumbar puncture, the cerebrospinal fluid usually flows out under pressure, transparent. His research reveals:

- cell-protein dissociation;

- lymphocytic pleocytosis (the number of cells increases to several hundred in 1 mm 3);

- normal or slightly increased content squirrel;

- high sugar content.

The nature of changes in the cerebrospinal fluid depends on the timing of the disease. Thus, the increase in cytosis may be delayed and in the first 4-5 days from the onset of the disease, the composition of the cerebrospinal fluid remains normal. In addition, sometimes, in the initial period, there is a short-term predominance of neutrophils in the CSF. After 2-3 weeks from the onset of the disease, protein-cell dissociation is detected. The course of the meningeal form of poliomyelitis is favorable and ends with complete recovery.

The inapparant form of poliomyelitis is characterized by the absence of clinical symptoms with the simultaneous isolation of the "wild" strain of the virus from feces and a diagnostic increase in the titer of antiviral antibodies in the blood serum.

The abortive form or minor illness is characterized by an acute onset, the presence of general infectious symptoms without involvement of the nervous system in the pathological process. So, children may experience fever, moderate lethargy, loss of appetite, headache. Often, these symptoms are combined with catarrhal or dyspeptic symptoms, which serves as the basis for the erroneous diagnosis of acute respiratory viral or intestinal infections. Usually, the abortive form is diagnosed during the hospitalization of the patient from the focus and receiving positive results virological examination. The abortive form proceeds benignly and ends with a complete recovery within a few days.

The development of vaccine-associated poliomyelitis is associated with the use of a live oral vaccine for mass immunization and the possibility of reversing the neurotropic properties of individual clones of vaccine virus strains. In this regard, in 1964, a special WHO committee determined the criteria by which cases of paralytic poliomyelitis can be classified as vaccine-associated:

- the onset of the disease is not earlier than the 4th and not later than the 30th day after vaccination. For those in contact with the vaccinated, this period is extended to the 60th day;

- development of flaccid paralysis and paresis without sensory impairment with persistent (after 2 months) residual effects;

- lack of progression of the disease;

- isolation of a polio virus similar in antigenic characteristics to the vaccine virus and at least a 4-fold increase in type-specific antibodies.

Treatment

Rest in bed is necessary until severe symptoms subside.

Pain medications may be used to reduce fever, pain, and muscle spasms.

Your doctor may prescribe bethanecol to treat urinary retention and antibiotics to treat urinary retention. bacterial infection urinary canal.

urinary catheter, a thin tube connected to a urine collection bag may be required if bladder control has been lost due to paralysis.

Artificial respiration may be required if breathing is difficult; in some cases, surgery to open the throat (tracheotomy) may be required.

Physiotherapy is necessary in cases of temporary or permanent paralysis. Mechanical aids such as bandages, crutches, a wheelchair, and special boots can help you walk.

A combination of professional and psychological therapy can help patients adjust to the limitations imposed by the disease.

Treatment of poliomyelitis in the acute period should be etiotropic, pathogenetic and symptomatic.

The development of clinical variants of poliomyelitis with damage to the nervous system requires mandatory, as early as possible hospitalization of the patient, ensuring careful care and constant monitoring of basic vital functions. It is necessary to observe a strict orthopedic regimen. The affected limbs are given physiological

position with the help of plaster splints, bandages. The diet should meet the age needs of the child in the main ingredients and provides for the exclusion of spicy, fatty, fried foods. Particular attention should be paid to feeding children with bulbar or bulbospinal forms, since due to impaired swallowing, the threat of developing aspiration pneumonia is real. To avoid this formidable complication allows tube feeding of the child.

As far as medical treatment is concerned, important point is the maximum limit intramuscular injections that contribute to the deepening of neurological disorders.

As etiotropic agents in meningeal and paralytic forms, it is necessary to use antiviral drugs (pleconaril, isoprinosine pranobex), interferons (viferon, roferon A, reaferon-EC-lipint, leukinferon) or inducers of the latter (neovir, cycloferon), immunoglobulins for intravenous administration.

Pathogenetic therapy of the acute period provides for the inclusion in complex therapy:

- glucocorticoid hormones (dexamethasone) in severe forms according to vital indications;

- vasoactive neurometabolites (trental, actovegin, instenon);

- nootropic drugs (gliatilin, piracetam, etc.);

- vitamins (A, B1, B 6 , B 12 , C) and antioxidants (vitamin E, mexidol, mildronate, etc.);

- diuretics (diacarb, triampur, furosemide) in combination with potassium-containing drugs;

— infusion therapy for the purpose of detoxification (5-10% glucose solutions with electrolytes, albumin, infucol);

- inhibitors of proteolytic enzymes (gordox, amben, contrykal);

- non-narcotic analgesics (with severe pain syndrome);

- physiotherapeutic methods (paraffin or ozocerite applications on the affected limbs, UHF on the affected segments).

The appearance of the first movements in the affected muscle groups marks the beginning of early recovery period and is an indication for the appointment of anticholinesterase agents (prozerin, galantamine, ubretide, oxazil). As you cup pain syndrome use exercise therapy, massage, UHF, then electrophoresis, electromyostimulation impulse current, hyperbaric oxygenation.

After discharge from the infectious diseases department, the course of treatment with the medications described above continues for 2 years. The optimal solution should be considered the treatment of polio convalescents in specialized sanatoriums.

It is not yet known whether the infection can be stopped once it has started. On the other hand, many children who become infected do not develop paralysis. Many who are paralyzed for a while then fully recover. Most of those who do not completely recover make a significant improvement.

If after acute phase disease there is a slight paralysis, the child should be under the constant supervision of a doctor. Treatment depends on many factors. At each stage, the decision is made by the doctor, and there is no general rules. If the paralysis persists, various operations are possible that restore the mobility of the limbs and protect them from deformation.

Prevention

When there are cases of polio in your area, parents start asking how to keep the child safe. Your local doctor will give you best advice. It makes no sense to panic and deprive children of all contact with others. If there are cases of illness in your area, it is wise to keep children away from crowds, especially in closed places such as shops and cinemas, and away from swimming pools that are used by many people. On the other hand, as far as we now know, it is absolutely not necessary to forbid a child to meet close friends. If you take care of him like that all your life, you won't even let him cross the street. Physicians suspect that hypothermia and fatigue increase susceptibility to the disease, but both are best avoided at all times. Of course, the most common case of hypothermia in the summer is when a child spends too much time in the water. When he begins to lose his color, he should be called out of the water before his teeth chatter.
. There are a number of vaccines that are recommended at two months of age, then again at four and 18 months, and a booster when the child enters school (between four and six years of age).

Childhood immunization is the backbone of the polio eradication strategy, with routine immunization coverage of at least 95% among children of decreed ages in accordance with the Calendar preventive vaccinations.

National Immunization Days - Second important component in the polio eradication strategy. The aim of these campaigns is to stop the circulation of "wild" poliovirus by immunizing as soon as possible (within a week) all children belonging to the age group with the most high risk diseases (as a rule, these are children under the age of three years).

In Russia, National Polio Immunization Days covering about 4 million children under the age of 3 years (99.2-99.5%) were held for 4 years (1996-1999). Immunization was carried out in two rounds, with an interval of one month, with a live oral polio vaccine (OPV), with vaccination coverage of at least 95% of the number of children of the indicated age groups located in the given territory.

The main prophylactic drug both in our country and throughout the world is the Sabin live vaccine (ZHA), recommended by WHO. In addition, in Russia registered imported vaccines Imovax Polio (Sanofi Pasteur, France), Tetrakok (Sanofi Pasteur, France). The Pentaxim vaccine (Sanofi Pasteur, France) is under registration. The listed vaccines belong to inactivated polio vaccines. Vaccines are stored at a temperature of 2-8 °C for 6 months. An opened vial should be used within two working days.

Currently, for immunization of the child population against poliomyelitis, OPV is used - oral types 1, 2 and 3 (Russia), IPV - Imovax Polio - inactivated enhanced (types 1, 2, 3) and Pentaxim (Sanofi Pasteur, France).

Vaccination starts from the age of 3 months three times with an interval of 6 weeks IPV, revaccination - at 18 and 20 months, and also at 14 years - OPV.

The dose of a domestically produced live vaccine is 4 drops per dose. It is administered by mouth one hour before meals. Drinking the vaccine, eating and drinking within an hour after vaccination is not allowed. When spitting up, a second dose should be given.

Contraindications for HPV vaccination are:

- all types of immunodeficiency;

- neurological disorders due to previous ZhPV vaccinations;

- the presence of acute diseases. In the latter case, the vaccine is given immediately after recovery.

Non-severe diseases with fever up to 38 °C are not a contraindication for ZhPV vaccination. In the presence of diarrhea, vaccination is repeated after normalization of the stool.

The oral polio vaccine is considered the least reactogenic. However, its use does not exclude the possibility of an adverse post-vaccination event. The greatest degree of risk is observed with primary vaccination and with contact infection of non-immune children.

It is possible to prevent the occurrence of vaccine-associated poliomyelitis in children, especially from risk groups (IDS, born from HIV-infected mothers, etc.), using inactivated polio vaccine for initial vaccination or after full course immunization.

According to epidemiological indications, additional immunization is carried out. It is carried out regardless of previous preventive vaccinations against poliomyelitis, but not earlier than 1 month after the last immunization. Children under 5 years of age are subject to a single OPV immunization (the age composition of children may be changed) who communicated in epidemic foci with patients with poliomyelitis, diseases accompanied by acute flaccid paralysis, if these diseases are suspected in the family, apartment, house, preschool educational and medical - a preventive institution, as well as those who communicated with those who arrived from territories unfavorable for poliomyelitis.

Non-specific prevention of polio infection involves hospitalization and isolation of the patient, the establishment of observation for 20 days for contact children under the age of 5 years. According to epidemiological indications, a single virological examination of contacts is carried out. In the epidemic focus of POLYO / AFP, after hospitalization of the patient, final disinfection is carried out.

In adults, polio vaccination is recommended only before traveling to places where polio is common.

Call your doctor immediately if you or your child are experiencing symptoms of polio or if you may have been exposed to the virus and have not yet been vaccinated.

See your doctor to get the polio vaccine if you have not been vaccinated and are going to travel where polio is common.

Attention! Call " ambulance” if someone is having difficulty breathing or is experiencing paralysis of a limb.

Flaccid or flaccid paralysis is a syndrome that occurs and develops when a peripheral neuron is damaged in any area: anterior horn, root, plexus, peripheral nerve, which has Negative consequences for the human motor system.

In medicine, flaccid and spastic paralysis are distinguished. Flaccid paralysis is characterized by a decrease in muscle tone and necrosis of the affected muscles. Spastic paralysis is characterized, on the contrary, by increased muscle tone, while patients cannot control the movement of the muscles of their body. Flaccid paralysis affects the peripheral nerve, and spastic paralysis affects the brain and spinal cord.

Flaccid paralysis disorders are characterized by the following features:

• Muscle atony (lack or decrease in muscle strength)
• Areflexia (absence of reflexes, which usually indicates an existing gap in the reflex arc)
• Hyporeflexia
• Muscular atrophy
• Violation of muscle electrical excitability
• Muscle atrophy or wasting

Peripheral (flaccid, atrophic) paralysis or paresis is a severe loss of motor function of a muscle or group of muscles.

One of the reasons the affected nervous system can be:

• Impaired circulation
• A brain tumor
• Hemorrhage of the brain or spinal cord or vascular disease
• Injuries
• Inflammatory diseases of the nervous system

Treatment of flaccid paralysis

Any treatment of flaccid paralysis is aimed at restoring (if possible) the function of a peripheral neuron, at preventing the development of muscle tissue atrophy.

But before thinking about the treatment of flaccid paralysis, one must understand that both paresis and paralysis are not independent diseases, but are formed as a result of other diseases and some pathological processes. Therefore, treatment, first of all, should be directed against the underlying disease.

The passage of physiotherapy for the treatment of flaccid paralysis is prescribed and carried out under the supervision of a physician.

Patients may be prescribed medication, neurosurgical intervention, massage.

Courses of physiotherapy treatment are prescribed in almost all cases of the disease, and in combination with drug treatment physical therapy gives the best results.

An important task is to prevent the development of muscle atrophy. because degeneration muscle fibers develops very quickly and is, unfortunately, irreversible.

Muscle atrophy can reach a very pronounced degree, when it will not be possible to restore muscle function. Therefore, with flaccid paralysis, you need to start as soon as possible prevention of atrophy . For this, massage, hydromassage, gymnastics, physiotherapy (electrical stimulation of nerves and muscles, magnetotherapy, ultrasound therapy, laser therapy, etc.) are prescribed.

Massage is aimed at stimulating the muscles, for this they do intensive rubbing, kneading with an effect on segmental zones. Massage for paralysis can be carried out for many months with short breaks between courses.

Electrical stimulation - takes special place in the treatment of flaccid paralysis with the help of physiotherapy. Usage electric current for the purpose of excitation and strengthening of muscle activity gives good results in treatment.

Electric current is able to change the concentration of tissue ions by cellular level, changing the permeability, and acts on the principle of biocurrents.

Therapeutic effect, during the course of treatment with the help of electrotherapy:

• improvement of blood flow to the muscles and metabolic processes
• increased tissue respiration
• acceleration of biochemical and enzymatic processes
• improved venous return
• increase in functional activity in the central nervous system.

The therapeutic effect directly depends on the parameters of the stimulating electric current (frequency, duration, shape and amplitude of the pulses), because correct appointment of these parameters for electrotherapy procedures is of great importance, individually for each person. Before a course of electrotherapy, it is necessary to pass diagnostic study degree of muscle denervation (electromyography).

Health Center "Las" treats flaccid paralysis with the presence of pain and severe trophic disorders.

Treatment, first of all, is complex, consisting of several physiotherapeutic procedures.

So, for example, in the presence of our Health Center there is a device for electrical stimulation and ultrasound therapy - "EXPERT" (IONOSON-EXPERT)(modern, multifunctional, combined, two-channel), which generates low and medium frequency currents.

These currents, with the help of the IONOSON-EXPERT device, can be precisely adapted to the required type of therapy using individual choice additional parameters (pulse length and shape, frequency, bursts, two-phase mode, and many others).

Two independent channels with individual setting of the current strength allow you to flexibly vary the types of therapeutic effects. Thus, it is possible to carry out simultaneous treatment with both current and ultrasound, as well as conduct combined therapy.

Our Health Center "LAS" has at its disposal the most modern devices for physiotherapy, brought from Germany.

During the campaign to eradicate poliomyelitis, the identification of all diseases that occur with symptoms of acute flaccid paralysis, which may include people with undiagnosed poliomyelitis, is of particular importance.

ACUTE FLEXIBLE PARALLY

Diagnosis of PM is a complex process, including clinical, laboratory (virological) and special (ENMG) confirmation of the diagnosis with observation of paralysis for at least 2 months and requires certain experience and skills

An accurate diagnosis of PM in rural areas and in outpatient settings is sometimes an impossible task.

Therefore, the control of cases of suspected PM is focused on the identification of AFP, which are similar in clinical symptoms to PM.

ACUTE FLEXIBLE PARALLY

When making a diagnosis of AFP, the following is taken into account:

History of present illness and previous life

Clinical symptom complex:

- hectic period

- meningo-radicular syndrome

- the time of appearance and development of paralysis and paresis,

- the nature of the paralysis (flaccid or spastic).

- neurological status (reflexes, tone, sensitivity, pelvic functions, muscle atrophy and other symptoms),

- duration of paralysis, etc.

Sample Collection Time and Results

Time of vaccinations and contact with vaccinated persons

Results of additional studies

ACUTE FLEXIBLE PARALLY

Characteristics of acute flaccid paralysis

The presence of paresis (limitation) or paralysis (lack of range of motion in the limbs)

Low muscle tone

Low or no tendon reflexes

Absence of pathological reflexes

Signs of damage to the anterior horns of the spinal cord

Diseases occurring with acute flaccid

I. polyradiculoneuropathy

paralysis

II. traumatic neuropathy

III. musculoskeletal dysplasia IV. myelitis

V. Poliomyelitis VI. tumors

VII. other diseases (hematomyelia, spinal epidural abscess, myelin and myelopathy, and others)

Polyradiculoneuropathy

(Guillain-Barre syndrome, Landry, Strol, Miller-Fischer,

acute polyradiculoneuritis)

Children get sick with a frequency of 1.1 per 100,000 population. The disease is often preceded by infections of the respiratory and

gastrointestinal tract

Etiology:

Campylobacter jejuni (30%)

cytomegalovirus (15%)

Epstein-Barr virus (10%)

Mycoplasma pneumoniae (5%), etc.

Polyradiculoneuropathy

There are 4 main clinical forms:

acute inflammatory demyelinating polyneuropathy (AIDP),

acute motor axonal neuropathy (OMAN),

acute motor-sensory axonal neuropathy (AMSAN),

Miller-Fischer syndrome

Polyradiculoneuropathy

occur without a rise in temperature against the background of a general satisfactory condition

gradual (within 1-2 weeks) development of neurological symptoms

in children with a temperature debut of the disease, the development of paresis / paralysis occurs against the background of normal temperature

paresis / paralysis begins with the distal extremities

are symmetrical

there are sensory disorders such as "stocking" and "gloves"

in CSF, an increase in protein numbers is often noted with normal cytosis

by the end of the 3rd week of illness, 85% of patients show signs of segmental demyelination and/or axonal degeneration on ENMG examination

Traumatic neuropathies

Post-injection mononeuropathies are the most common. When collecting an anamnesis, it is possible to identify an association with an intramuscular injection that preceded the development of neuropathy.

Other causes are less commonly identified: falls and injuries of the spine, compression of the limb with a tight bandage, infringement of the limb in the crib or playpen

Neuromuscular diseases

The "flaccid child" syndrome can be observed in a number of diseases:

congenital muscular dystrophy

spinal progressive muscle atrophy(Verdnig-Hoffmann, Fazio-Londe, etc.)

atonic form of cerebral palsy

benign form of congenital hypotension

some other diseases

Acute paralytic poliomyelitis of non-poliovirus etiology mainly proceeded in the form of mild (in 46.3%) and moderate (in 28%) forms (Table 2). Clinical Analysis showed that the severity of the disease is determined by the biological properties of the pathogen. Thus, severe and moderate forms of the disease were observed in patients with yersiniosis and enterovirus nature of the disease, while mild forms of the disease were observed with influenza and enterovirus. Viral poliomyelitis (in 57.4%) prevailed over bacterial (in 7.4%). Enteroviruses 68-71 (in 56.7%), Coxsackieviruses (in 10%) and ECHO 1-6, 7-13, 25, 30 (in 31.2%) were etiologically significant in their development. Enteroviral poliomyelitis was characterized by severity radicular syndrome, the frequent development of ataxia and unstable oculomotor disorders, relapses of the disease (in 11%), compared with influenza, characterized by motor disorders and acute course. Poliomyelitis of yersiniosis etiology, as a rule, was a multiple polyneuropathy and occurred subacutely on the 2nd-4th wave of the underlying disease in severe cases or in cases of late etiotropic therapy. Distinctive features there were asymmetry, but bilateral symptoms with damage to the proximal parts of the lower extremities, involvement in the process of thoracic and abdominal muscles, the presence of vegetative-trophic disorders, the severity of the pain syndrome with a characteristic multi-wave protracted course, but a favorable outcome with adequate antibiotic therapy. Proof autonomic disorders there were data doppler ultrasound and thermal imaging survey. Moderate decrease in linear blood flow velocity due to spastic-dystonic changes vascular tone observed in the lungs clinical symptoms, more significant - in severe. A disorder of neurotrophic functions with severe neurological symptoms was manifested on thermograms by a distinct decrease in infrared radiation in the corresponding area, coinciding with the zone of neurological disorders, in mild cases - a picture of diffuse vegetative irritation in the form of zones of hypo- or hyperthermia. These studies indicate vegetative-vascular disorders and peripheral hemodynamic disorders in acute flaccid paralysis, which contributes to nerve ischemia and serves as the basis for the development of myelin and axonopathies.

The outcomes of acute paralytic poliomyelitis of non-poliovirus etiology also differed depending on the severity of the disease (Table 3). If, with a mild course of the disease, all children were healthy before discharge, then with a moderate course of the disease, only 53% of patients, and with a severe course, neurological symptoms persisted in all children, and in 28% there was a decrease in tendon reflexes, in 50% - muscle hypotension in the proximal sections, in 13% - hypotrophy of the muscles of the thigh and buttocks after 60 days from the onset of the disease. In general, by the time of discharge, 61% of the children were healthy, in 29% the recovery process lasted up to 3 months, in 7% - up to 6 months, and in 2% - up to a year.

It is interesting that out of 93 patients admitted to the clinic with a diagnosis, 39 had their diagnosis removed. Competing diseases include:

In children with a pathological obstetric history and the presence of pyramidal symptoms against the background of an acute respiratory viral infection that occurs with intoxication, fever, a paretic gait appeared, which tends to change during the day: either decrease or increase. High tendon reflexes were determined, in 1/2 cases with pathological signs and foot clonus. Negative results virological examination, unfavorable premorbid background in children, the presence of hemiparesis and obvious signs ARI, the absence of electroneuromyographic abnormalities in the lesion of the peripheral motor neuron made it possible to change the diagnosis to decompensation of natal CNS injuries due to ARI.

Diseases of the musculoskeletal system and injuries were diagnosed in 7 children, including 2 - arthritis, 2 - osteomyelitis, 3 - ischemic myelopathy. In all cases, the disease was manifested by a pronounced pain syndrome, gentle gait, local skin changes (with osteomyelitis) without electroneuromyographic abnormalities.

A tumor of the spinal cord was suspected in 2 children admitted 3-4 weeks after the onset of the disease. Attention was drawn to the gradual increase in neurological symptoms, spasticity in the legs, the absence of positive dynamics from the therapy, and the presence of electroneuromyographic signs of spinal lesions with irritation. Subsequently, the diagnosis was confirmed by nuclear magnetic resonance imaging of the spinal cord. After an intramuscular injection into the buttock, 4 children developed flaccid paresis of the leg into which the injection was made. With traumatic neuritis sciatic nerve the paresis extended only to the posterior muscle group of the leg, while the anterior group, innervated by the femoral nerve, was intact. An electroneuromyographic examination revealed a decrease in the speed of impulse conduction both along the motor and sensory fibers of the sciatic nerve and the presence of a block of conduction, which was not observed with.

In the treatment of acute paralytic poliomyelitis of non-poliovirus etiology, the traditional principle of etiotropic and pathogenetic therapy, adopted in infectious diseases, is mandatory. Of particular importance in acute period flaccid paralysis has an adequate etiotropic antibacterial or antiviral treatment. An integral part of therapy at this stage is the creation of absolute rest for the patient, compliance with the orthopedic regimen, the exclusion of intramuscular injections and the relief of pain. The new pathogenetic therapy is fundamental, consisting in the early and continuous administration of vasoactive neurometabolites (instenon or actovegin, or trental, etc.). In moderate and severe forms of the disease, the appointment of dehydration agents (diacarb, etc.), non-steroidal anti-inflammatory drugs (indomethacin, brufen, piroxicam, etc.) is justified, one of the main mechanisms of action of which is the inhibition of the synthesis of prostaglandins, which are potential vasodilators that cause autonomic failure. The duration of admission ranges from 2 to 4 weeks, depending on the severity of the symptoms. It is important to consistently carry out physiotherapeutic methods of treatment (UHF, electrophoresis, ozocerite applications, electrical muscle stimulation), massage, exercise therapy, acupuncture.

conclusions

2. The severity of neurological symptoms in acute flaccid paralysis depends on the severity and duration of exposure infectious agent, biological properties of the pathogen, which determine the degree of vegetative-trophic disorders due to a disorder in the regulation of vascular tone, nerve ischemia and the development of myelino- and axonopathy. In patients with yersinia and enterovirus (enteroviruses 68-71, ECHO 1-6) etiology of the disease, severe and moderate forms prevail, with influenza and viral (Coxsackie and ESNO 7-13, 25, 30) - light.

3. The frequency of diagnostic errors (42%) indicates the need for a thorough clinical and neurological examination of children admitted with flaccid paresis, with the aim of timely correct diagnosis and early adequate therapy.

4. Treatment of patients with acute flaccid paralysis includes the mandatory conduct of adequate etiotropic therapy, continuous administration of vasoactive neurometabolites, non-steroidal anti-inflammatory drugs against the backdrop of consistent physiotherapy, massage, exercise therapy and compliance with the orthopedic regimen.

Russian Bulletin of Perinatology and Pediatrics, N3-1999, p.31-35

Literature

1. Infectious morbidity in the North-West region of Russia. Analytical review, ed. A.B. Zhebruna et al. St. Petersburg: Research Institute im. Pasteur 1998; 64.

2. Guidance for additional activities aimed at the eradication of poliomyelitis. WHO: Geneva 1997; 56.

3. Leshchinskaya E.V., Latysheva I.N. Clinic, diagnosis and treatment of acute poliomyelitis. Method. recommendations. M 1998; 47.

4. Order N 56/237 dated 6.08.98. four.

5. Clouston P.D., Kiers L., Zuniga G., Cros D. Quantitative analysis of the compound muscle action potential in early acute inflammatory demyelinating polyneuropathy. Electroencephalogr Clin Neurophysiol 1994; 93:4:245-254.

Two groups of neurons are responsible for voluntary movements of the human body, namely, peripheral and central. They have different structure and differ in their functions. Therefore, the manifestations of the disease are different.

If there is a violation in the work of the central neurons, spastic paralysis develops, while with deviations in the functioning of peripheral neurons, flaccid paralysis occurs.

Central paralysis provokes a general impairment of motor activity. A person develops spasticity of muscle fibers, however, along with this, they do not lose their integrity and do not undergo atrophy. With the development of central paralysis in certain groups of muscle tissue, clinical convulsions appear, but deep tendon reflexes are completely preserved.

With this form of paralysis, it often appears positive symptom Babinsky, in which thumb lower limb performs a flexion movement when the foot is irritated.

With paralysis of a peripheral nature, a decrease in muscle tone is observed and atrophic processes develop. At the same time, there are no deep tendon reflexes, while abdominal reflexes are preserved. Also, this form of paralysis is characterized by a negative symptom of Babinsky. Often people complain of loss of sensitivity.

Kinds

Exist different types diseases - classification is carried out depending on the severity of disorders, manifestations and prevalence of the pathological process. So, doctors distinguish complete and incomplete paralysis. It can also be reversible and irreversible, be local or widespread.

Depending on the affected area, there is:

To indicate the number of limbs affected by the pathological process, doctors use the following terms:

Paralysis as a separate disease

In most cases, paresis and paralysis do not act as independent diseases. They are a symptom that indicates organic lesions of the central nervous system. However, there are some types of paralysis that are independent diseases.

How to treat

In most cases, paralysis and paresis are not independent diseases. Therefore, effective treatment is impossible without adequate therapy of the underlying pathology.

If there is damage to the peripheral nerve, it is required to restore its integrity. For this purpose, a neurosurgical operation is performed.

If a person has had a stroke, he needs to undergo a full course of rehabilitation treatment. When a tumor formation appears that compresses the nerve endings or brain structures, it should be removed.

Therapy of paralysis in the event of a stroke requires the restoration of the work of the affected area and the activation of neighboring zones, which are able to take on the lost functions. For this, several categories of drugs are used:

Of no small importance is the symptomatic treatment of the disease. To restore the functioning of the limbs, it is very important to properly position them on the bed. This will reduce the risk of developing contractures.

An important component of complex therapy is physiotherapy and massage. Thanks to kneading the affected limbs and stimulating the nerve endings of the muscles, it is possible to restore broken connections with the central zones of the cortex.

Peripheral paralysis lends itself well to electrotherapy and other physiotherapy techniques. Most often, doctors prescribe galvanization and balneotherapy. In this case, massage and special exercises are also very effective.

There are no methods of therapeutic exercises for the treatment of facial paralysis, and therefore such types of therapy are considered ineffective. Thanks to the use of drugs, it is possible to stimulate the restoration of the myelin sheath and the transmission of impulses.

For this, B vitamins, aloe, vitreous body. The same drugs are used during the rehabilitation period after performing an operation to restore the integrity of the nerves.

Tunneling neuropathies can be successfully treated with topical drug blockades. During this procedure, painkillers and anti-inflammatory drugs and vitamin preparations are injected into the affected area. Thanks to this, it is possible to restore muscle mobility in a short time.

Paralysis is a fairly serious condition, which in most cases is a symptom of more dangerous pathologies. To cope with this ailment, it is very important to establish the causes of its occurrence, and for this it is important to consult an experienced doctor as soon as possible.

Paralysis of the legs is a loss of motor abilities caused by damage to the spinal cord. Paralysis can be complete or partial. In the second case, they speak of paresis. Paralysis may indicate the development a large number diseases. With paralysis of the limbs, one should carefully monitor the dynamics of the state change ....