Poliomyelitis

Kaempferol: A Review of Current Evidence of Its Antiviral Potential

Kaempferol and its derivatives are flavonoids found in various plants, and a considerable number of these have been used in various medical applications worldwide. Kaempferol and its compounds have well-known antioxidant, anti-inflammatory and antimicrobial properties among other health benefits. However, the antiviral properties of kaempferol are notable, and there is a significant number of experimental studies on this topic. Kaempferol compounds were effective against DNA viruses such as hepatitis B virus, viruses of the alphaherpesvirinae family, African swine fever virus, and pseudorabies virus; they were also effective against RNA viruses, namely feline SARS coronavirus, dengue fever virus, Japanese encephalitis virus, influenza virus, enterovirus 71, poliovirus, respiratory syncytial virus, human immunodeficiency virus, calicivirus, and chikungunya virus. On the other hand, no effectiveness against murine norovirus and hepatitis A virus could be determined. The antiviral action mechanisms of kaempferol compounds are various, such as the inhibition of viral polymerases and of viral attachment and entry into host cells. Future research should be focused on further elucidating the antiviral properties of kaempferol compounds from different plants and assessing their potential use to complement the action of antiviral drugs.

Comparative Study on MNVT of OPV Type I and III Reference Products in Different Periods

Widespread vaccination using the oral live attenuated polio vaccine (OPV) and Sabin strain inactivated vaccine (sIPV) have greatly reduced the incidence of polio worldwide. In the period post-polio, the virulence of reversion of the Sabin strain makes the use of OPV gradually becoming one of the major safety hazards. The verification and release of OPV has become the top priority. The monkey neurovirulence test (MNVT) is the gold standard for detecting whether OPV meets the criteria, which are recommended by the WHO and Chinese Pharmacopoeia. Therefore, we statistically analyzed the MNVT results of type I and III OPV at different stages: 1996-2002 and 2016-2022. The results show that the upper and lower limits and C value of the qualification standard of type I reference products in 2016-2022 have decreased compared with the corresponding scores in the 1996-2002 period. The upper and lower limit and C value of the qualified standard of type III reference products were basically the same as the corresponding scores in the 1996-2002. We also found significant differences in the pathogenicity of the type I and III in the cervical spine and brain, with the decreasing trend in the diffusion index of the type I and type III in the cervical spine and brain. Finally, two evaluation criteria were used to judge the OPV test vaccines from 2016 to 2022. The vaccines all met the test requirements under the evaluation criteria of the above two stages. Based on the characteristics of OPV, data monitoring was one of the most intuitive methods to judge changes in virulence.

Combating a resurgence of poliomyelitis through public health surveillance and vaccination

Poliomyelitis, or polio, is a highly infectious disease and can result in permanent flaccid paralysis of the limbs. Singapore was certified polio-free by the World Health Organization (WHO) on 29 October 2000, together with 36 other countries in the Western Pacific Region. The last imported case of polio in Singapore was in 2006. Fortunately, polio is vaccine-preventable—the world saw the global eradication of wild poliovirus types 2 and 3 achieved in 2015 and 2019, respectively. However, in late 2022, a resurgence of paralytic polio cases from vaccine-derived poliovirus (VDPV) was detected in countries like Israel and the US (specifically, New York); VDPV was also detected during routine sewage water surveillance with no paralysis cases in London, UK. Without global eradication, there is a risk of re-infection from importation and spread of wild poliovirus or VDPV, or new emergence and circulation of VDPV. During the COVID-19 pandemic, worldwide routine childhood vaccination coverage fell by 5% to 81% in 2020–2021. Fortunately, Singapore has maintained a constantly high vaccination coverage of 96% among 1-year-old children as recorded in 2021. All countries must ensure high poliovirus vaccination coverage in their population to eradicate poliovirus globally, and appropriate interventions must be taken to rectify this if the coverage falters. In 2020, WHO approved the emergency use listing of a novel oral polio vaccine type 2 for countries experiencing circulating VDPV type 2 outbreaks. Environmental and wastewater surveillance should be implemented to allow early detection of “silent” poliovirus transmission in the population, instead of relying on clinical surveillance of acute flaccid paralysis based on case definition alone. Keywords: Acute flaccid paralysis, infectious diseases, polio vaccine, poliovirus, surveillance

Polio returns to the USA: An epidemiological alert

On July 21, 2022, the USA witnessed the first case of poliomyelitis after 3 decades of its eradication. Poliomyelitis is a crippling disease that results from infection with any one of the three related poliovirus types (referred to as types P1, P2, and P3), members of the enterovirus (picornavirus) family. The New York State Department of Health confirmed that a case of paralytic poliomyelitis was reported from a 20-year-old Hungarian traveller residing in Rockland County. The detected viral sequence has been found to have vaccine-derived poliovirus type 2 (VDPV2) suggesting an origin from the live attenuated oral polio vaccine (OPV). Since immunisation remains the only preventable measure, this article explores suggestions from the Centers for Disease Control and Prevention on reliable Inactivated (killed) polio vaccination in high-risk patients along with early case detection and treatment. In light of the above-mentioned findings, this research further details future recommendations like cessation of the OPV, encouragement of inactivated polio vaccine (IPV) in vaccination schedules, sensitive epidemiological surveillance system and appropriate training for healthcare providers. The affected countries have been further advised to have effective outbreak response strategy plans in place so that they can respond and stay prepared for such outbreaks in the future.

Postpolio Syndrome from Non-paralytic Poliovirus Infection

A 73-year-old man presented with muscle weakness and atrophy of his right arm. Atrophy of his left brachia and left calf had occurred 13 years before without any improvement or deterioration. His sister and cousin had a history of paralytic poliomyelitis. Serum poliovirus type 2 neutralizing antibody was elevated to 128×. Electromyography revealed chronic denervation potentials not only in the muscles affected previously but also in the unaffected muscles. Acute and chronic denervation potentials were found in the newly affected muscle. Postpolio syndrome should be considered in patients with unilateral muscular atrophy even when they have no history of paralytic poliomyelitis.

Outcomes Following Total Hip Arthroplasty in Patients With Postpolio Syndrome: A Matched Cohort Analysis

BACKGROUND

Patients with postpolio syndrome (PPS) may be afflicted by hip arthritis in either the paralytic or contralateral limb. Total hip arthroplasty (THA) may be considered in these patients. However, short-term and long-term outcomes following THA in PPS patients remain poorly characterized.

METHODS

The PearlDiver MHip administrative database was queried for patients undergoing THA. Patients with a diagnosis of PPS were matched 1:4 with control patients on the basis of age, gender, and comorbidity burden. Incidence of postoperative adverse events and readmission in the 90 days following surgery and occurrence of revision arthroplasty in the five-year postoperative period were assessed between the two cohorts.

RESULTS

In total, 1,519 PPS patients were matched to 6,076 control patients without PPS. After controlling for patient demographics and comorbidities, PPS patients demonstrated higher 90-day odds of urinary tract infection (odds ratio [OR] = 1.34, P = .016), pneumonia (OR = 2.07, P < .001), prosthetic dislocation (OR = 1.63, P = .018), and readmission (OR = 1.49, P = .002). Five years following surgery, 94.7% of the PPS cohort remained revision-free, compared to 96.7% of the control cohort (P = .001).

CONCLUSION

Compared to patients without PPS, patients with PPS demonstrated a higher incidence of urinary tract infection, pneumonia, prosthetic dislocation, and hospital readmission. In addition, five-year incidence of revision arthroplasty was significantly higher among the PPS cohort. In light of these increased risks, special considerations should be made in both preoperative planning and postoperative surveillance of PPS patients undergoing THA.

LEVEL OF EVIDENCE

Level III.

A Historical Review of Military Medical Strategies for Fighting Infectious Diseases: From Battlefields to Global Health

The environmental conditions generated by war and characterized by poverty, undernutrition, stress, difficult access to safe water and food as well as lack of environmental and personal hygiene favor the spread of many infectious diseases. Epidemic typhus, plague, malaria, cholera, typhoid fever, hepatitis, tetanus, and smallpox have nearly constantly accompanied wars, frequently deeply conditioning the outcome of battles/wars more than weapons and military strategy. At the end of the nineteenth century, with the birth of bacteriology, military medical researchers in Germany, the United Kingdom, and France were active in discovering the etiological agents of some diseases and in developing preventive vaccines. Emil von Behring, Ronald Ross and Charles Laveran, who were or served as military physicians, won the first, the second, and the seventh Nobel Prize for Physiology or Medicine for discovering passive anti-diphtheria/tetanus immunotherapy and for identifying mosquito Anopheline as a malaria vector and plasmodium as its etiological agent, respectively. Meanwhile, Major Walter Reed in the United States of America discovered the mosquito vector of yellow fever, thus paving the way for its prevention by vector control. In this work, the military relevance of some vaccine-preventable and non-vaccine-preventable infectious diseases, as well as of biological weapons, and the military contributions to their control will be described. Currently, the civil-military medical collaboration is getting closer and becoming interdependent, from research and development for the prevention of infectious diseases to disasters and emergencies management, as recently demonstrated in Ebola and Zika outbreaks and the COVID-19 pandemic, even with the high biocontainment aeromedical evacuation, in a sort of global health diplomacy.

Is Poliomyelitis Sequelae A Disadvantage for Recovery from Covid-19 ARDS: A Case Report

We present a case with acute respiratory distress syndrome due to COVID-19 who had poliomyelitis sequelae. He was hospitalized in the intensive care unit and supported by non-invasive mechanical ventilation for 7 days. IL-6 inhibitor was administered due to cytokine storm. No steroid or sedative agents were administered. Early mobilization was performed in the intensive care unit. One month after discharge, physical examination revealed COVID-19 infection did not cause significant changes in muscle strength and physical performance in this patient with poliomyelitis sequelae. It is important to promote early mobilization in the intensive care unit to prevent post-intensive care syndrome in COVID-19 acute respiratory distress syndrome.

Significant Asymmetry of the Bilateral Upper Extremities of a Skeleton Excavated from the Mashiki-Azamabaru Site, Okinawa Island, Japan

The human skeleton of a young adult male with marked asymmetry of the bilateral upper extremities was excavated from the Mashiki-Azamabaru site (3000–2000 BCE) on the main island of Okinawa in the southwestern archipelago of Japan. The skeleton was buried alone in a corner of the cemetery. In this study, morphological and radiographic observations were made on this skeleton, and the pathogenesis of the bone growth disorder observed in the left upper limb was discussed. The maximum diameter of the midshaft of the humerus was 13.8 mm on the left and 21.2 mm on the right. The long bones comprising the left upper extremity lost the structure of the muscle attachments except for the deltoid tubercle of the humerus. The bone morphology of the right upper extremity and the bilateral lower extremities was maintained and was close to the mean value of females from the Ohtomo site in northwestern Kyushu, Japan, during the Yayoi period. It is assumed that the anomalous bone morphology confined to the left upper extremity was secondary to the prolonged loss of function of the muscles attached to left extremity bones. In this case, birth palsy, brachial plexus injury in childhood, and acute grey matter myelitis were diagnosed. It was suggested that this person had survived into young adulthood with severe paralysis of the left upper extremity due to injury or disease at an early age.

The neurological sequelae of pandemics and epidemics

Neurological manifestations in pandemics frequently cause short and long-term consequences which are frequently overlooked. Despite advances in the treatment of infectious diseases, nervous system involvement remains a challenge, with limited treatments often available. The under-recognition of neurological manifestations may lead to an increase in the burden of acute disease as well as secondary complications with long-term consequences. Nervous system infection or dysfunction during pandemics is common and its enduring consequences, especially among vulnerable populations, are frequently forgotten. An improved understanding the possible mechanisms of neurological damage during epidemics, and increased recognition of the possible manifestations is fundamental to bring insights when dealing with future outbreaks. To reverse this gap in knowledge, we reviewed all the pandemics, large and important epidemics of human history in which neurological manifestations are evident, and described the possible physiological processes that leads to the adverse sequelae caused or triggered by those pathogens.

Neurologic Conditions Associated with Cavus Foot Deformity

The cavus foot deformity is an often less understood deformity within the spectrum of foot and ankle conditions. The hallmark concern is the possibility of an underlying neurologic or neuromuscular disorder. Although a proportion of these deformities are idiopathic, a significant majority do correlate with an underlying disorder. The appropriate evaluation of this deformity, in coordination within the multidisciplinary scope of health care, allows for a timely diagnosis and understanding of the patient's condition. We provide an abbreviated survey of possible underlying etiologies for the patient with the cavus foot deformity as a reference to the foot and ankle surgeon.

Palliative Care for Polio and Postpolio Syndrome

Palliative care is a team-based approach focusing on relief of physical, psychosocial, and existential distress and communication about serious illness. Patients with poliomyelitis and postpolio syndrome are at risk for contractures and can benefit from involvement of physical and occupational therapy. Hypersialorrhea can be treated with anticholinergic medications, botox, or radiation. Patients with dyspnea may require noninvasive positive pressure ventilation ± opioids or benzodiazepines. Constipation is often due to autonomic dysfunction and decreased mobility. There is a higher burden of anxiety. Early conversations about patients' goals and values as it relates to their health may help frame future decision-making.

Doctor-Should I get the COVID-19 vaccine? Infection and immunization in individuals with neuromuscular disorders

The clinical course of neuromuscular disorders (NMDs) can be affected by infections, both in immunocompetent individuals, and in those with reduced immunocompetence due to immunosuppressive/immunomodulating therapies. Infections and immunizations may also trigger NMDs. There is a potential for reduced efficacy of immunizations in patients with reduced immunocompetence. The recent vaccination program for coronavirus disease-2019 (COVID-19) raises several questions regarding the safety and efficacy of this vaccine in individuals with NMDs. In this Practice Topic article, we address the role of vaccine-preventable infections in NMDs and the safety and efficacy of immunization in individuals with NMDs, with emphasis on vaccination against COVID-19.

Primary breast cancer patient with poliomyelitis: A case report

BACKGROUND

Poliomyelitis is an acute infection caused by an enterovirus, which primarily infects the human gastrointestinal tract. In general, patients with polio have no association with the occurrence of cancer. The present case study presents a rare case of poliomyelitis combined with primary breast cancer.

CASE SUMMARY

A 61-year-old woman who was diagnosed with poliomyelitis at 5 years old and confirmed invasive breast cancer by core needle biopsy (CNB) after hospitalization. The patient received a modified radical mastectomy and four cycles of chemotherapy with the TC (docetaxel and cyclophosphamide) regimen. The patient was also prescribed endocrine therapy without radiotherapy after chemotherapy. The patient had no evidence of lymphedema in the right upper extremities and no evidence of either regression or distant metastasis at the 1-year follow-up.

CONCLUSION

The pectoral muscles of patients with polio are easily damaged in traumatic procedures, such as CNB, local anesthesia for tumor excision, and general anesthesia for surgery. A CNB, modified radical mastectomy, and four cycles of TC chemotherapy were successfully completed for the present case and the adverse reactions were found to be tolerable. This case may indicate the relationship between breast cancer and polio, and the examination and treatment methods used could be used as a guide for similar cases in the future.

Altered mental status in "Guillain-Barré syndrome" -a noteworthy clinical clue

Guillain-Barré syndrome (GBS) is widely regarded as a "pure" peripheral nervous system disorder. However, this simplistic interpretation belies the fact that central nervous system involvement, often manifesting as derangements in mental status can occur as a complication of the "pure" form of the disorder, as part of GBS variants, as well as in a number of mimic disorders. Despite being common in clinical practice, there is no guidance in the literature as to how to approach such scenarios. Herein, we detail our approach to these cases.

Management Options and Outcomes for Patients with Femoral Fractures with Post-Polio Syndrome of the Lower Extremity: A Critical Analysis Review

Post-polio syndrome is characterized by a late functional deterioration (usually after >=15 years from the initial infection) in patients with a history of paralytic poliomyelitis infection, and it is defined by the March of Dimes criteria. Patients with post-polio syndrome are at increased risk for falls and associated hip and femoral fractures as a result of lower bone mineral density, decreased lean muscle mass, and musculoskeletal deformities. Current evidence suggests that treatment modalities for femoral fractures should emphasize fixation that allows early progressive weight-bearing and ambulation to optimize functional outcomes. Good results after hip arthroplasty have been described with both cemented and uncemented implants in patients who have been treated for osteoarthritis, but there has been little evidence guiding hip fracture management. Anatomic challenges that are encountered are osteoporotic bone, a valgus neck-shaft angle, increased femoral anteversion, and a small femoral canal diameter. Intramedullary nailing of hip and femoral fractures can be challenging due to the small femoral canal diameter that frequently is encountered. Alternative methods of fixation have shown promising results. These include the use of sliding hip screws for hip fracture management and fixed-angle locking plates for hip and femoral fracture management.

Epidemic poliomyelitis, post-poliomyelitis sequelae and the eradication program

Epidemics of paralytic poliomyelitis (polio) first emerged in the late 19th and early 20th centuries in the United States and the Scandinavian countries. They continued through the first half of the 20th century becoming global. A major epidemic occurred in Australia in 1951 but significant outbreaks were reported from the late 1930s to 1954. The poliovirus is an enterovirus that is usually transmitted by the faecal–oral route but only one in about 150 infections results in paralysis when the central nervous system is invaded. The Salk inactivated polio vaccine (IPV) became available in Australia in 1956 and the Sabin live attenuated oral polio vaccine (OPV) was introduced in 1966. After decades of stability, many survivors of the earlier epidemics experience late-onset sequelae including post-polio syndrome. The World Health Organization launched the global polio eradication initiative (GPEI) in 1988 based on the easily administered OPV. The GPEI has resulted in a dramatic decrease in cases of wild polio so that only Pakistan and Afghanistan report such cases in 2020. However, a major challenge to eradication is the reversion of OPV to neurovirulent mutants resulting in circulating vaccine-derived poliovirus (cVDPV). A novel, genetically stabilised OPV has been developed recently to stop the emergence and spread of cVDPV and OPV is being replaced by IPV in immunisation programs worldwide. Eradication of poliomyelitis is near to achievement and the expectation is that poliomyelitis will join smallpox as dreaded epidemic diseases of the past that will be consigned to history.

Infectious Myelopathies

PURPOSE OF REVIEW

This article reviews bacterial, viral, fungal, and parasitic pathogens associated with myelopathy. Infectious myelopathies may be due to direct infection or parainfectious autoimmune-mediated mechanisms; this article focuses primarily on the former.

RECENT FINDINGS

Some microorganisms exhibit neurotropism for the spinal cord (eg, enteroviruses such as poliovirus and flaviviruses such as West Nile virus), while others are more protean in neurologic manifestations (eg, herpesviruses such as varicella-zoster virus), and others are only rarely reported to cause myelopathy (eg, certain fungal and parasitic infections). Individuals who are immunocompromised are at increased risk of disseminated infection to the central nervous system. Within the last few years, an enterovirus D68 outbreak has been associated with cases of acute flaccid paralysis in children, and emerging Zika virus infection has been concurrent with cases of acute flaccid paralysis due to Guillain-Barré syndrome, although cases of myelitis have also been reported. Associated pathogens differ by geographic distribution, with myelopathies related to Borrelia burgdorferi (Lyme disease) and West Nile virus more commonly seen in the United States and parasitic infections encountered more often in Latin America, Southeast Asia, and Africa. Characteristic CSF and MRI patterns have been identified with many of these infections.

SUMMARY

A myriad of pathogens are associated with infectious myelopathies. Host factors, geographic distribution, clinical features, CSF profiles, and MRI findings can assist in formulating the differential diagnosis and ultimately guide management.

Enteroviruses: Classification, Diseases They Cause, and Approaches to Development of Antiviral Drugs

The genus Enterovirus combines a portion of small (+)ssRNA-containing viruses and is divided into 10 species of true enteroviruses and three species of rhinoviruses. These viruses are causative agents of the widest spectrum of severe and deadly epidemic diseases of higher vertebrates, including humans. Their ubiquitous distribution and high pathogenici- ty motivate active search to counteract enterovirus infections. There are no sufficiently effective drugs targeted against enteroviral diseases, thus treatment is reduced to supportive and symptomatic measures. This makes it extremely urgent to develop drugs that directly affect enteroviruses and hinder their development and spread in infected organisms. In this review, we cover the classification of enteroviruses, mention the most common enterovirus infections and their clinical man- ifestations, and consider the current state of development of anti-enteroviral drugs. One of the most promising targets for such antiviral drugs is the viral Internal Ribosome Entry Site (IRES). The classification of these elements of the viral mRNA translation system is also examined.

Abnormalities of respiratory control and the respiratory motor unit

BACKGROUND

Control of ventilation depends on a brainstem neuronal network that controls activity of the motor neurons innervating the respiratory muscles. This network includes the pontine respiratory group and the dorsal and ventral respiratory groups in the medulla. Neurologic disorders affecting these areas or the respiratory motor unit may lead to abnormal breathing.

REVIEW SUMMARY

The brainstem respiratory network contains neurons critical for respiratory rhythmogenesis; this network receives inputs from peripheral and central chemoreceptors sensitive to levels of carbon dioxide (PaCO2) and oxygen (PaO2) and from forebrain structures that control respiration as part of integrated behaviors such as speech or exercise. Manifestations associated with disorders of this network include sleep apnea and dysrhythmic breathing frequently associated with disturbances of cardiovagal and sympathetic vasomotor control. Common disorders associated with impaired cardiorespiratory control include brainstem stroke or compression, syringobulbia, Chiari malformation, high cervical spinal cord injuries, and multiple system atrophy. By far, neuromuscular disorders are the more common neurologic conditions leading to respiratory failure.

CONCLUSIONS

Respiratory dysfunction constitute an early and relatively major manifestation of several neurologic disorders and may be due to an abnormal breathing pattern generation due to involvement of the cardiorespiratory network or more frequently to respiratory muscle weakness.

Postpolio syndrome: a challenge to the health-care system

The practical eradication of poliomyelitis in industrialized countries marks one of the most important achievements of world health policy. Yet, disability induced by polio not only continues to exist among survivors with paralytic sequelae, but may also be further accentuated in a considerable number of affected subjects by the development of postpolio syndrome (PPS). PPS aggravates the motor sequelae already present in such subjects and reduces their functional capacity to the point where it affects their activities of daily living and worsens their quality of life. Inasmuch as development of PPS questions the concept of poliomyelitis as a static disease it poses a challenge not only to health professionals but also to policy-makers tasked with providing the necessary health-care measures and appropriate resources. This study sought to review research on this syndrome and to draw up some recommendations that might prove useful to the health authorities for decision-making purposes.

Electrodiagnostic features of acute paralytic poliomyelitis associated with West Nile virus infection

West Nile virus (WNV) infection is a potentially fatal disease, with meningoencephalitis being its most common neurological manifestation. Guillain-Barré syndrome (GBS) has also been described, but acute paralytic poliomyelitis has only recently been recognized. We report the clinical and electrodiagnostic findings of five patients with WNV infection, who presented with acute paralytic poliomyelitis. Three patients manifested focal asymmetrical weakness, and two had rapid ascending quadriplegia mimicking GBS. Electrodiagnostic studies during the acute illness showed normal sensory nerve action potentials, compound motor action potentials of normal or reduced amplitude, and no slowing of nerve conduction velocities. Depending on the timing of the examination, fibrillation potentials were widespread, including in those with focal weakness. Cervical magnetic resonance imaging in one patient showed abnormal T2-weighted signals in the spinal cord gray matter. On follow-up, signs of clinical improvement were seen in one patient, whereas two remained quadriplegic and ventilator-dependent 5 months after the onset. This report highlights the value of the electrodiagnostic studies in the diagnosis and prognosis of focal or generalized weakness due to acute paralytic poliomyelitis associated with WNV infection.

Respiratory aspects of neurological disease

Neurological disease may result in respiratory dysfunction; however the manifestations of respiratory dysfunction in such patients may be atypical because of wider effects of their underlying condition. In the present review we have considered separately acute neuromuscular respiratory disease (as well as aspects of respiratory muscle function relevant to intensive care), chronic neuromuscular respiratory disease, sleep related disorders, respiratory consequences of specific neurological diseases, and neurological features of respiratory disease. Approaches to specific clinical problems are discussed; in many instances this can be expedited by close cooperation with a respiratory physician. We suggest that management of respiratory dysfunction in neurological disease depends critically on three factors: firstly, knowledge of when respiratory dysfunction is likely to occur; secondly, maintaining a high index of clinical suspicion (specifically apparently vague symptoms should not be uncritically attributed to the underlying neurological condition); and, thirdly, the pursuing of appropriate investigations.