Polio differential diagnosis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: João André Alves Silva, M.D. [2]

Overview

Abortive poliomyelitis must be differentiated from other diseases that cause fever, nausea, vomiting, diarrhea, headache, and sore throat, such as gastroenteritis or acute respiratory infection.[1][2]

Paralytic poliomyelitis must be differentiated from other diseases that cause headache, muscle pain, lethargy, muscle weakness, spams, and tremors, such as Guillain-Barré syndrome, traumatic neuritis of the sciatic nervev transverse myelitisv and West Nile Virus.[2][1][3][4][5][6]

Differential Diagnosis

The table below summarizes the findings that differentiate poliomyelitis from other conditions that cause headache, fever, muscle pain; nausea and vomiting:[2][1][3][4][5][6][7]

Abortive Poliomyelitis

Disease Findings
Gastroenteritis Self-limited condition that often presents with abdominal pain, diarrhea, fever, loss of appetite; nausea and vomiting. It may be differentiated from abortive poliomyelitis with serologic tests.
Acute respiratory infection Often presents with nasal discharge or congestion, sore throat, cough, fever, headache, malaise, and muscle weakness. It may be differentiated from abortive poliomyelitis with serologic tests.

Paralytic Poliomyelitis

The table below summarizes the findings that differentiate poliomyelitis from other conditions that cause headache, muscle pain; lethargy, muscle weakness, spams and tremors:[2][1][3][4][5][6][7]

Disease Findings
Guillain-Barré syndrome Often presents with distal, ascending, symmetrical paralysis with abolished reflexes. Unlike paralytic poliomyelitis, it does not cause muscular atrophy, or skeletal deformities.
Traumatic neuritis of the sciatic nerve Often occurs few days after intramuscular injections, presenting with pain and decreased temperature of the affected limb. Unlike paralytic poliomyelitis, it has an injection as causative agent, and does not cause muscular atrophy, or skeletal deformities.
Transverse myelitis Often presents as symmetrical, flaccid paresis, decreased sensory level and neurogenic bladder. Unlike paralytic poliomyelitis, it does not typically cause skeletal deformities.
West Nile Virus May present as a mild disease, with abdominal pain, diarrhea, fever, headache, and myalgia, or as a more severe form, that may be life-threatening, called West Nile encephalitis, which may present with: confusion, muscle weakness, and stiff neck. It may be differentiated from paralytic poliomyelitis with serologic tests.
Encephalitis Often occurs with fever; confusion; irritability; vomiting; and stiff neck. Commonly, it does not present with paralysis and may be differentiated from paralytic poliomyelitis with serologic tests.


The following table differentiates poliomyelitis from other diseases that cause muscle weakness, hypotonia, and flaccid paralysis:[8][8][9][10][11][12][13][14][15][16][17][18][19][20][21][22][23]

Diseases History and Physical Diagnostic tests Other Findings
Motor Deficit Sensory deficit Cranial nerve Involvement Autonomic dysfunction Proximal/Distal/Generalized Ascending/Descending/Systemic Unilateral (UL)

or Bilateral (BL)

or

No Lateralization (NL)

Onset Lab or Imaging Findings Specific test
Adult Botulism + - + + Generalized Descending BL Sudden Toxin test Blood, Wound, or Stool culture Diplopia, Hyporeflexia, Hypotonia, possible respiratory paralysis
Infant Botulism + - + + Generalized Descending BL Sudden Toxin test Blood, Wound, or Stool culture Flaccid paralysis (Floppy baby syndrome), possible respiratory paralysis
Guillian-Barre syndrome[24] + - - - Generalized Ascending BL Insidious CSF: ↑Protein

↓Cells

Clinical & Lumbar Puncture Progressive ascending paralysis following infection, possible respiratory paralysis
Eaton Lambert syndrome[25] + - + + Generalized Systemic BL Intermittent EMG, repetitive nerve stimulation test (RNS) Voltage gated calcium channel (VGCC) antibody Diplopia, ptosis, improves with movement (as the day progresses)
Myasthenia gravis[26] + - + + Generalized Systemic BL Intermittent EMG, Edrophonium test Ach receptor antibody Diplopia, ptosis, worsening with movement (as the day progresses)
Electrolyte disturbance[27] + + - - Generalized Systemic BL Insidious Electrolyte panel ↓Ca++, ↓Mg++, ↓K+ Possible arrhythmia
Organophosphate toxicity[28] + + - + Generalized Ascending BL Sudden Clinical diagnosis: physical exam & history Clinical suspicion confirmed with RBC AchE activity History of exposure to insecticide or living in farming environment. with : Diarrhea, Urination, Miosis, Bradycardia, Lacrimation, Emesis, Salivation, Sweating
Tick paralysis (Dermacentor tick)[29] + - - - Generalized Ascending BL Insidious Clinical diagnosis: physical exam & history - History of outdoor activity in Northeastern United States. The tick is often still latched to the patient at presentation (often in head and neck area)
Tetrodotoxin poisoning[30] + - + + Generalized Systemic BL Sudden Clinical diagnosis: physical exam & dietary history - History of consumption of puffer fish species.
Stroke[31] +/- +/- +/- +/- Generalized Systemic UL Sudden MRI +ve for ischemia or hemorrhage MRI Sudden unilateral motor and sensory deficit in a patient with a history of atherosclerotic risk factors (diabetes, hypertension, smoking) or atrial fibrillation.
Poliomyelitis[32] + + + +/- Proximal > Distal Systemic BL or UL Sudden PCR of CSF Asymmetric paralysis following a flu-like syndrome.
Transverse myelitis[33] + + + + Proximal > Distal Systemic BL or UL Sudden MRI & Lumbar puncture MRI History of chronic viral or autoimmune disease (e.g. HIV)
Neurosyphilis[34][23] + + - +/- Generalized Systemic BL Insidious MRI & Lumbar puncture CSF VDRL-specifc

CSF FTA-Ab -sensitive[35]

History of unprotected sex or multiple sexual partners.

History of genital ulcer (chancre), diffuse maculopapular rash.

Muscular dystrophy[36] + - - - Proximal > Distal Systemic BL Insidious Genetic testing Muscle biopsy Progressive proximal lower limb weakness with calf pseudohypertrophy in early childhood. Gower sign positive.
Multiple sclerosis exacerbation[37] + + + + Generalized Systemic NL Sudden CSF IgG levels

(monoclonal)

Clinical assessment and MRI [38] Blurry vision, urinary incontinence, fatigue
Amyotrophic lateral sclerosis[39] + - - - Generalized Systemic BL Insidious Normal LP (to rule out DDx) MRI & LP Patient initially presents with upper motor neuron deficit (spasticity) followed by lower motor neuron deficit (flaccidity).
Inflammatory myopathy[40] + - - - Proximal > Distal Systemic UL or BL Insidious Elevated CK & Aldolase Muscle biopsy Progressive proximal muscle weakness in 3rd to 5th decade of life. With or without skin manifestations.

References

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