Neuromuscular

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INFECTIONS & MYELOPATHY

General
  CSF features
  Geographic distribution

Abscess
AIDS
Central European encephalitis
CSF eosinophilia
Dengue
Enterovirus: D68; 71
HIV
HTLV I & II
Parasites
Poliomyelitis: Acute
Spirochete
Tuberculosis
Varicella zoster
West Nile
Whipple's

Neuromuscular Disorders
Spinal cord tabes (Gowers manual)

Tabes dorsalis



General features 4

Geographic Distribution
Myelopathies: CSF features

Protein  Glucose  Cells
Abscess High Low Neutrophils
Tuberculosis High Low Lymphocytes
Virus High Normal Lymphocytes
Fungus High Low Lymphocytes
Parasite High Normal Eosinophils
Immune High Normal Lymphocytes

Polio

  • Polio virus
    • Enterovirus
      • RNA, single stranded
      • Subgroup of Picornaviridae
      • 3 serotypes
        • All can cause paralytic disease
        • Type 1: Most common cause of epidemic paralytic polio
    • Transmission: Fecal-Oral
    • Human susceptibility
      • 2° to Polio virus receptor (PVR; CD155; NECL5)
    • Spread: Lymphatics to Blood to CNS
    • Neurons: Virus replicates & releases RNA into cytoplasm
  • Epidemiology
    • Outbreaks: Most common in late summer
    • Affected patients: Usually > 6 month of age; 6 mo to 3 years
    • Most cases: Afghanistan, Nigeria, Pakistan, Egypt, Syria
    • Paralytic disease
      • 1% to 2% of infections
      • More likely with increased age
      • Male > Female
  • Course: Events after viral exposure
    • Asymptomatic with viremia: 90% to 95%
    • Minor illness: 1 to 5 days after exposure
      • Fever
      • Malaise, Myalgia
      • Sore throat, GI upset
    • Major illness
      • Timing: 4 to 20 days post-infection; Usually < 1 week
      • Aseptic meningitis
      • Fever
      • Pain
        • Headache
        • Stiff neck & Back pain: Muscle stiffness
    • Paralytic disease
      • Frequency
        • 50% of those with major illness
        • 0.1% to 1% of infected patients; Mean 0.2%
      • Timing: After 2 to 5 days of illness; Up to 3 weeks
      • Motor: Weakness +
        • Onset: Fulminent, Acute, or Subacute
        • Focal or Asymmetric
        • Proximal > Distal
        • Legs > Arms > Bulbar (20%)
        • Tendon reflexes
          • Early
            • May be increased
          • Paralytic phase
            • Reduced in affected limbs after 12 to 24 hours
        • Muscle atrophy: After 2 to 3 weeks
        • Course
          • Improvement
            • Onset: After few weaks
            • Maximal: At 6 to 9 months
          • Residual weakness: 60% to 70%
      • Dysautonomia, Acute
        • Blood pressure instability
        • Cardiac arrhythmia
        • GI: Atony, Constipation
        • Urinary retention
        • Sweating: Increased or Decreased
      • Other clinical
        • Fasciculations: Localized
        • Pain: Intense myalgia, hyperesthesia
      • Mortality
        • Children: 2% to 5%
        • Adults: 15% to 30%
      • Differential diagnosis
      • Lab
        • CSF
          • Pleocytosis
            • Acute: Polys
            • > 72 hours: Lymphocytes
            • Clear from CSF after 1 week
          • Protein: High; Increase over 1st 3 weeks
        • Diagnostic
          • Serology
            • Serum: 4-fold titer rise
            • CSF: IgM poliovirus specific
          • Culture: Stool positive in 90% by 20 days
        • Electrodiagnostic
          • Early
            • Selective loss of motor axons at 7 to 10 days
              • CMAP amplitudes small
            • NCV: Normal velocities
            • Sensory: Normal
          • EMG
            • Acute
              • Fibrillations & PSW: After 2 to 3 weeks
              • Reduced recruitment
            • Chronic
              • CMAPs: Large amplitude; Long duration
        • Spinal cord pathology: Anterior horn
          • Inflammation
            • Perivascular
            • Mononuclear cell
          • Anterior horn cells
            • Loss
            • Abnormal morphology
            • Chromatolysis
        • Muscle: Chronic
          • Fiber type grouping: Large
  • Also see

Wikipedia
Polio: Leg atrophy Egypt 1403-1365 BC

From Bramwell: Atlas of Clinical Medicine
Polio: Arm atrophy


From Bramwell: Diseases of the Spinal Cord
Polio: Small ventral horn

Polio: Abnormal motor neuron cell bodies


Polio: Spinal cord perivascular inflammation
From Barnes & Miller: Brain 1907;30;101

Other Viruses

Varicella zoster Acquired Immunodeficiency Syndrome (AIDS)

R. Schmidt
HIV myelopathy
Human T-cell lymphotrophic virus, Type I (HTLV I) 3 Human T-cell lymphotrophic virus, Type II 2

Spirochetes


Tuberculosis


Parasitic infections


Abcesses


Whipple's disease



CSF eosinophilia



Also see Infections & Neuromuscular Disease
Return to Myelopathies
Return to Neuromuscular Home Page

1. Neurology 1996;46:1016-1021
2. Ann Neurol 1996;40:714-723
3. J Neurological Sci 2003;206:1721, Semin Neurol 2005;25:315-327
4. Continuum 2012;18:1351-1373

10/13/2022