Acute paralytic poliomyelitis should be considered whenever an at-risk patient presents with an acute febrile illness, aseptic meningitis, and asymmetric flaccid paralysis associated with the loss of deep tendon reflexes and normal sensation. As with other causes of aseptic meningitis, the CSF reveals pleocytosis during the first week after paralysis onset. The CSF white cell count can elevate into the hundreds, with a predominance of neutrophils early in the disease course. These cells allow noninflammatory causes of paralysis to be excluded from the differential diagnosis. Although the poliovirus can be cultured from the CSF early in the disease course, throat and rectal swabs will provide a greater yield. When a particular viral serotype is identified, serial serum antibody titers can be used to verify the cultures.
The most important cause of paralysis that must be excluded is Guillain-Barré syndrome, which, unlike the acute polio infection, causes more symmetric muscle weakness. Acute paralysis can result from peripheral neuropathies caused by infectious mononucleosis, Lyme disease, or porphyria. Paralysis also can result from inflammatory myopathies, electrolyte abnormalities, toxins, or other viruses, such as Coxsackie, mumps, echoviruses, and nonpolio enteroviruses. Paralysis also can result from acute spinal cord compression, vascular lesions, and myelitis, all of which should produce a sensory level and sphincter disturbances. In children, it is necessary to rule out spinal muscular atrophy, which can be undiagnosed until it is manifested by dramatic limb weakness caused by an acute febrile illness.
In order to diagnose postpolio syndrome, the patient should have a history of acute paralytic poliomyelitis with stable recovery of motor function associated with residual muscle atrophy, weakness, and areflexia with normal sensation in at least one limb. Additionally, there should be new muscle symptoms or weakness not attributable to an acute injury, neuropathy, radiculopathy, or systemic, neurologic, or psychiatric illness.
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