|Ahead of print publication
Acute flaccid paralysis in an infant
Antonieo Jude Raja Balraj1, Rohit Bhowmick2, Ananthanarayanan Kasinathan1, Peter Prasanth Kumar Kommu1
1 Department of Pediatrics, Pondicherry Institute of Medical Sciences, Puducherry, India
2 Department of Pediatrics, AIIMS, Kalyani, West Bengal, India
|Date of Submission||04-Nov-2021|
|Date of Decision||14-Jul-2022|
|Date of Acceptance||14-Jul-2022|
|Date of Web Publication||17-Sep-2022|
Antonieo Jude Raja Balraj,
Department of Pediatrics, Pondicherry Institute of Medical Sciences, Puducherry
Source of Support: None, Conflict of Interest: None
The incidence rate of acute flaccid myelitis (AFM) in India was 12/100,000 people, whereas it is 0.71/million in the United States. The incidence of nonpolio AFM has increased over the years. We present a young infant with a 3-day fever followed by irritability and paucity of movements of the left lower limb for 24 hours. The initial laboratory evaluation was negative for bacterial meningitis. However, a polymerase chain reaction was used to detect enterovirus ribonucleic acid in cerebrospinal fluid. The patient's condition improved as a result of supportive care. This case shows a serious nonpolio enteroviral central nerve infection that presents as acute flaccid paralysis.
Keywords: Acute flaccid myelitis, acute flaccid paralysis, acute flaccid myelitis syndrome, enterovirus, myelitis
| Introduction|| |
Recently, India has been declared a polio-free nation after remarkable progress in eradicating wild poliovirus transmission. Despite the achievement of polio eradication, a rising number of nonpolio-acute flaccid paralysis (NP-AFP) cases are documented each year. Enteroviruses (EVs) are the most common cause of viral meningitis, almost at all ages at which the cause is identified. We present a young infant presented with monoparesis, which is unusual for bacterial meningitis.
| Case Report|| |
A 2.5-month-old baby presented with concerns about a 3-day fever and 24-hour irritable crying. He was also noted to have recurrent episodes of uprolled eyes and reduced responsiveness lasting 3-5 seconds. The child's food acceptance was poor and their sleep cycle was altered. On the 3rd day of the illness, before hospitalization, the mother noticed reduced movement in her left leg while crying. There was no significant history of ear discharge, rash, or crying while micturition. His perinatal period was unremarkable, and his family history was noncontributory. His documented immunization status was age appropriate.
On examination, the child was afebrile, irritable, and with poor hydration status. Vitals were stable. Anthropometry was unremarkable. There were no bulging anterior fontanelles. The left lower limb was flaccid with poor antigravity movements and absent reflexes. The plantar reflex showed an extensor response. The rest of the systemic examination was unremarkable. Given the history of fever with seizures with irritability and flaccid monoparesis of the left lower limb, differential diagnoses considered were acute central nervous system (CNS) infection and stroke. Investigations revealed anemia (10.1 g/dL), neutrophilic leukocytosis, and elevated C-reactive protein. Cerebrospinal fluid (CSF) analysis revealed no cells with normal protein and sugar was normal. The blood and CSF cultures were sterile. The CSF meningoencephalitis polymerase chain reaction (PCR) panel was positive for enterovirus infection [Table 1].
|Table 1: Molecular biology meningoencephalitis panel (deoxyribonucleic acid)|
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Magnetic resonance imaging (MRI) of the brain and whole spine was normal at admission. The 21-channel electroencephalogram in an awake and sleep state revealed no abnormalities. An echocardiogram was unremarkable. The left lower limb nerve conduction study revealed acute motor axonal neuropathy. Stool samples for poliovirus were negative. A final diagnosis of enteroviral flaccid meningoencephalitis/myelitis was made. Empiric antibiotics were stopped and supportive measures were initiated, including early physical rehabilitation. At the 6-month follow-up, the child was gaining developmental milestones for age and had a minimally noticeable deficit in the left leg. Follow-up at 2 years revealed normal power in the left lower limb without any residual deficit. There were no further seizures.
| Discussion|| |
EVs are the most common cause of viral meningitis in infants, and their neurological spectrum includes CNS features associated with aseptic meningitis, meningoencephalitis, and demyelinating illness. They may have peripheral nervous system features of paralytic poliomyelitis or NP flaccid myelitis with respiratory involvement. Our case merits attention for the following reasons: the symptoms and the severity are age dependent, with maximal deficits noted in children <90 days of age, as reported by Berardi et al.
The very young age of onset of illness, as in the index child, requires early identification and appropriate supportive management. Second, the diagnosis of acute flaccid myelitis (AFM) is predominantly clinical, supplemented by the identification of the virus by PCR testing. The absence of MRI evidence of flaccid myelitis has been well described in AFM, especially in the early phase of the illness. This has been reiterated by studies by Okumura et al. and Madaan and Saini who have illustrated the poor radiological agreement and ill-defined widespread spinal involvement in early cases., Third, rapid identification of enterovirus viruses has demonstrated a significant reduction in hospital stays and also aids physicians in the holistic management of severe disease from the onset. This also helps in the judicious use and stoppage of antibiotics in acute care settings, as reported by Seoane Rodríguez et al. Molecular characterization of the NP EV isolates to identify the genotypes was not feasible in the index child due to financial restraints.
| Conclusion|| |
NP enterovirus is a leading cause of aseptic meningitis in children and a high index of clinical suspicion in infants with fever and monoparesis is crucial for early diagnosis.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the father has given his consent for his child's clinical information to be reported in the journal. He understands that the name and initials will not be published and due efforts will be made to conceal the identity, but anonymity cannot be guaranteed.
I would like to thank the team of doctors who were involved in the care of the child.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
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Okumura A, Mori H, Fee Chong P, Kira R, Torisu H, Yasumoto S, et al.
Serial MRI findings of acute flaccid myelitis during an outbreak of enterovirus D68 infection in Japan. Brain Dev 2019;41:443-51.
Madaan P, Saini L. Nerve transfers in acute flaccid myelitis: A beacon of hope. Pediatr Neurol 2019;93:68.
Seoane Rodríguez M, Cañizares Castellanos A, Avila-Alvarez A. Enteroviral meningitis in infants under 3 months. Enferm Infecc Microbiol Clin 2017;35:680-1.