5-80
Diet: As tolerated. Increase fluids.
Medications: Acetaminophen (instead of aspirin) for pain and fever to avoid risk of Reye’s Syndrome.
Prevention and Hygiene: Avoid close contact with others until well after secretions resolve.
No Improvements/Deterioration: Return immediately for sudden onset of severe abdominal pain, or fainting
or lightheadedness after abdominal trauma.
Follow-up Actions
Return Evaluation: Examine liver and spleen carefully, for tenderness, enlargement or rupture.
Evacuation/Consultation criteria: Evacuate patient with enlarged spleen prophylactically, to avoid emer-
gent evacuation (and poor prognosis) for a ruptured spleen. Otherwise, evacuation is not typically necessary,
unless patient becomes unstable or is too fatigued to complete the mission. Consult primary care physician,
infectious disease specialist or pulmonologist as needed, and consult a general surgeon urgently for a
suspected splenic rupture.
ID: Poliovirus
LTC Niranjan Kanesa-thasan, MC, USAIntroduction: Poliovirus is an enterovirus spread through fecal or pharyngeal secretions and associated with
outbreaks of paralytic poliomyelitis. The incubation period to illness is 7-14 days following respiratory or oral
exposure to infectious poliovirus. Typically enterovirus infections are asymptomatic or minor febrile illnesses.
Only about 1% of polio infections result in clinically apparent neurologic disease. Geographic Association:
Polio is primarily a disease associated with poor sanitation and is found primarily in the developing countries
of Asia and Africa. It has been eradicated from the Western hemisphere through immunization, except in rare
cases of importation from endemic areas. Seasonal Variation: None in the tropics. In the past, clusters of
infections occurred during fall months in temperate regions. Risk Factors: Outbreaks occur in unvaccinated
populations, typically those living in poorer conditions or those objecting to immunization. While rare (<5%
of symptomatic poliovirus infections), the frequency of paralytic polio increases with increasing age at time
of infection. Secondary problems: Myelitis, peripheral neuropathy; Guillian-Barre syndrome (post-infectious
polyneuritis)
Subjective: Symptoms
Malaise, headache, nausea, vomiting, and sore throat; uneventful recovery within several days (abortive
poliomyelitis); 10-20% of symptomatic infections progress with severe muscle spasms, neck and back stiff-
ness, and muscle tenderness lasting about 10 days with complete recovery (nonparalytic poliomyelitis); few
develop paralytic poliomyelitis: asymmetric weakness or paralysis.
Focused History: Have you completed the full polio vaccination series? (drastically reduces chance of
polio infection) Did fever precede the limb weakness? (Flaccid limb paralysis, especially if asymmetric, after
acute febrile illness in a child or young adult is probable polio until proven otherwise.) Have you traveled
overseas or otherwise been exposed to poliovirus (including vaccine virus) recently? (travel to endemic area
[see above] or other contact within past several weeks establishes risk for infection).
Objective: Signs
Using Basic Tools: Vitals: Fever; rarely, respiratory embarrassment leading to paralysis
Inspection: Various findings: asymmetric flaccid paralysis from lower motor neuron damage (spinal poliomyeli-
tis); paralysis of respiratory muscles or bulbar paralysis leading to respiratory embarrassment; cranial nerve
palsies without sensory loss or dysphagia; deep tendon reflexes diminished or lost asymmetrically.
Palpation: Nuchal (neck) rigidity.
Assessment:
Differential Diagnosis
Mumps, tuberculous meningitis (TB) or brain abscess (see topics).
Two other enteroviruses are associated with asymmetric flaccid limb paralysis (in particular coxsackievirus A7
and enterovirus 71); in these rare cases, the clinical picture is identical to polio.