Acute Flaccid Paralysis in Children: Model Clinical Case and Viva QnA

Clinical Case of Acute Flaccid Paralysis in Children

Clinical Case: Acute Flaccid Paralysis

A 4-year-old boy, previously healthy, is brought to the emergency department by his parents with complaints of sudden onset weakness in both legs. The symptoms started 2 days ago and have rapidly progressed.

History:

• No recent history of trauma or injury
• Mild fever (38.1°C) and general malaise 5 days prior to onset of weakness
• No recent vaccinations
• No recent travel
• No known tick bites

Physical Examination:

• Alert and oriented
• Vital signs: Temperature 37.8°C, Heart rate 110/min, Respiratory rate 24/min, BP 100/60 mmHg
• Neurological examination:
  • Flaccid paralysis of both lower limbs (power 1/5 bilaterally)
  • Absent deep tendon reflexes in lower limbs
  • Decreased muscle tone in affected limbs
  • Sensory function intact
  • No involvement of upper limbs or cranial nerves
  • No bladder or bowel involvement
• Other systems: Unremarkable

Investigations:

• Complete blood count: Mild leukocytosis (12,000/μL)
• CSF analysis:
  • Protein: 65 mg/dL (slightly elevated)
  • Glucose: 60 mg/dL (normal)
  • WBC: 15 cells/μL (slightly elevated)
• MRI spine: Enhancement of cauda equina nerve roots
• Stool culture: Pending

Initial Management:

• Admission to pediatric intensive care unit for close monitoring
• Supportive care
• Initiation of intravenous immunoglobulin (IVIG)
• Physiotherapy
• Further investigations to determine etiology (viral studies, neuromuscular studies)

Differential Diagnosis:

• Guillain-Barré syndrome
• Acute poliomyelitis
• Transverse myelitis
• Acute flaccid myelitis

This case presents a typical scenario of acute flaccid paralysis in a pediatric patient, highlighting the importance of prompt recognition, thorough examination, and appropriate management.

2. Clinical Presentations of Acute Flaccid Paralysis in Children

Clinical Presentations of Acute Flaccid Paralysis in Children

1. Classic Ascending Paralysis (Guillain-Barré Syndrome)

   • Rapid onset of symmetrical weakness starting in the legs and ascending to arms
   • Absent or diminished deep tendon reflexes
   • Possible facial weakness or ophthalmoplegia
   • Potential respiratory involvement in severe cases
   • Preceded by viral illness or gastrointestinal infection in many cases

2. Focal Limb Weakness (Acute Flaccid Myelitis)

   • Sudden onset of limb weakness, often asymmetrical
   • Predominantly affects one or more limbs
   • Associated with gray matter lesions on MRI
   • May be accompanied by fever and respiratory symptoms
   • Potential for rapid progression and respiratory failure

3. Bulbar Paralysis (Poliomyelitis or Brainstem Encephalitis)

   • Weakness of muscles innervated by cranial nerves
   • Difficulties with swallowing, speaking, or facial expressions
   • Possible involvement of respiratory muscles
   • May be accompanied by fever and meningeal signs

4. Acute Transverse Myelitis

   • Rapid onset of bilateral leg weakness
   • Sensory level deficit
   • Bladder and bowel dysfunction
   • Clear spinal cord lesion on MRI

5. Todd's Paralysis (Post-ictal)

   • Temporary paralysis following a seizure
   • Typically unilateral and resolves within 24-48 hours
   • History of seizure activity

6. Tick Paralysis

   • Ascending flaccid paralysis
   • Begins in lower extremities and ascends
   • Associated with attached tick, often found in scalp or axilla
   • Rapid improvement after tick removal

7. Hypokalemic Periodic Paralysis

   • Episodic weakness, often triggered by rest after exercise or high-carbohydrate meals
   • May affect all four limbs
   • Associated with low serum potassium levels
   • Family history may be present

8. Botulism

   • Descending flaccid paralysis
   • Begins with cranial nerve involvement (diplopia, ptosis, dysarthria)
   • Progresses to limb and respiratory muscle weakness
   • Associated with constipation and poor feeding in infants

9. Acute Myositis

   • Sudden onset of muscle pain and weakness, often in calves
   • May follow viral illness
   • Elevated creatine kinase levels
   • Usually self-limiting

10. Spinal Cord Compression

    • Acute onset of weakness, often with a sensory level
    • May be associated with back pain
    • History of trauma or presence of spinal abnormality
    • MRI shows cord compression

These presentations highlight the diverse etiologies and manifestations of acute flaccid paralysis in children, emphasizing the need for a thorough clinical assessment and targeted investigations to determine the underlying cause and guide appropriate management.

Knowledge Check: Question and Answers for Medical Students & Professionals

This interactive quiz component covers essential viva questions and answers. It includes 30 high-yield viva questions with detailed answers.

Question 1 of 30

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