Polio differential diagnosis

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief:  João André Alves Silva, M.D. [2]

## Overview

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Abortive poliomyelitis must be differentiated from other diseases that cause fever, nausea, vomiting, diarrhea, headache, and sore throat, such as gastroenteritis or acute respiratory infection.[1][2]

Paralytic poliomyelitis must be differentiated from other diseases that cause headache, muscle pain, lethargy, muscle weakness, spams, and tremors, such as Guillain-Barré syndrome, traumatic neuritis of the sciatic nervev transverse myelitisv and West Nile Virus.[2][1][3][4][5][6]

## Differential Diagnosis

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The table below summarizes the findings that differentiate poliomyelitis from other conditions that cause headache, fever, muscle pain; nausea and vomiting:[2][1][3][4][5][6][7]

### Abortive Poliomyelitis

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Disease | Findings

|

Gastroenteritis | Self-limited condition that often presents with abdominal pain, diarrhea, fever, loss of appetite; nausea and vomiting. It may be differentiated from abortive poliomyelitis with serologic tests.
Acute respiratory infection | Often presents with nasal discharge or congestion, sore throat, cough, fever, headache, malaise, and muscle weakness. It may be differentiated from abortive poliomyelitis with serologic tests.

### Paralytic Poliomyelitis

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The table below summarizes the findings that differentiate poliomyelitis from other conditions that cause headache, muscle pain; lethargy, muscle weakness, spams and tremors:[2][1][3][4][5][6][7]

Disease | Findings

|

Guillain-Barré syndrome | Often presents with distal, ascending, symmetrical paralysis with abolished reflexes. Unlike paralytic poliomyelitis, it does not cause muscular atrophy, or skeletal deformities.
Traumatic neuritis of the sciatic nerve | Often occurs few days after intramuscular injections, presenting with pain and decreased temperature of the affected limb. Unlike paralytic poliomyelitis, it has an injection as causative agent, and does not cause muscular atrophy, or skeletal deformities.
Transverse myelitis | Often presents as symmetrical, flaccid paresis, decreased sensory level and neurogenic bladder. Unlike paralytic poliomyelitis, it does not typically cause skeletal deformities.
West Nile Virus | May present as a mild disease, with abdominal pain, diarrhea, fever, headache, and myalgia, or as a more severe form, that may be life-threatening, called West Nile encephalitis, which may present with: confusion, muscle weakness, and stiff neck. It may be differentiated from paralytic poliomyelitis with serologic tests.
Encephalitis | Often occurs with fever; confusion; irritability; vomiting; and stiff neck. Commonly, it does not present with paralysis and may be differentiated from paralytic poliomyelitis with serologic tests.

The following table differentiates poliomyelitis from other diseases that cause muscle weakness, hypotonia, and flaccid paralysis:[8][8][9][10][11][12][13][14][15][16][17][18][19][20][21][22][23]

Diseases | History and Physical  | Diagnostic tests | Other Findings

|
|
|

Motor Deficit | Sensory deficit | Cranial nerve Involvement | Autonomic dysfunction | Proximal/Distal/Generalized | Ascending/Descending/Systemic | Unilateral (UL)

or Bilateral (BL)

No Lateralization (NL)

| Onset | Lab or Imaging Findings | Specific test
Adult Botulism  | \+  | \-  | \+  | \+  | Generalized  | Descending  | BL  | Sudden  | Toxin test  | Blood, Wound, or Stool culture  | Diplopia, Hyporeflexia, Hypotonia, possible respiratory paralysis
Infant Botulism  | \+  | \-  | \+  | \+  | Generalized  | Descending  | BL  | Sudden  | Toxin test  | Blood, Wound, or Stool culture  | Flaccid paralysis (Floppy baby syndrome), possible respiratory paralysis
Guillian-Barre syndrome[24] | \+  | \-  | \-  | \-  | Generalized  | Ascending  | BL  | Insidious  | CSF: ↑Protein

↓Cells

| Clinical & Lumbar Puncture  | Progressive ascending paralysis following infection, possible respiratory paralysis
Eaton Lambert syndrome[25] | \+  | \-  | \+  | \+  | Generalized  | Systemic  | BL  | Intermittent  | EMG, repetitive nerve stimulation test (RNS)  | Voltage gated calcium channel (VGCC) antibody  | Diplopia, ptosis, improves with movement (as the day progresses)
Myasthenia gravis[26] | \+  | \-  | \+  | \+  | Generalized  | Systemic  | BL  | Intermittent  | EMG, Edrophonium test | Ach receptor antibody  | Diplopia, ptosis, worsening with movement (as the day progresses)
Electrolyte disturbance[27] | \+  | \+  | \-  | \-  | Generalized  | Systemic  | BL  | Insidious  | Electrolyte panel  | ↓Ca++, ↓Mg++, ↓K+  | Possible arrhythmia
Organophosphate toxicity[28] | \+  | \+  | \-  | \+  | Generalized  | Ascending  | BL  | Sudden  | Clinical diagnosis: physical exam & history  | Clinical suspicion confirmed with RBC AchE activity  | History of exposure to insecticide or living in farming environment. with : Diarrhea, Urination, Miosis, Bradycardia, Lacrimation, Emesis, Salivation, Sweating
Tick paralysis (Dermacentor tick)[29] | \+  | \-  | \-  | \-  | Generalized  | Ascending  | BL  | Insidious  | Clinical diagnosis: physical exam & history  | \-  | History of outdoor activity in Northeastern United States. The tick is often still latched to the patient at presentation (often in head and neck area)
Tetrodotoxin poisoning[30] | \+  | \-  | \+  | \+  | Generalized  | Systemic  | BL  | Sudden  | Clinical diagnosis: physical exam & dietary history  | \-  | History of consumption of puffer fish species.
Stroke[31] | +/-  | +/-  | +/-  | +/-  | Generalized  | Systemic  | UL  | Sudden  | MRI +ve for ischemia or hemorrhage  | MRI  | Sudden unilateral motor and sensory deficit in a patient with a history of atherosclerotic risk factors (diabetes, hypertension, smoking) or atrial fibrillation.
Poliomyelitis[32] | \+  | \+  | \+  | +/-  | Proximal > Distal  | Systemic  | BL or UL  | Sudden  |  | PCR of CSF  | Asymmetric paralysis following a flu-like syndrome.
Transverse myelitis[33] | \+  | \+  | \+  | \+  | Proximal > Distal  | Systemic  | BL or UL  | Sudden  | MRI & Lumbar puncture | MRI  | History of chronic viral or autoimmune disease (e.g. HIV)
Neurosyphilis[34][23] | \+  | \+  | \-  | +/-  | Generalized  | Systemic  | BL  | Insidious  | MRI & Lumbar puncture | CSF VDRL-specifc

CSF FTA-Ab -sensitive[35]

| History of unprotected sex or multiple sexual partners.

History of genital ulcer (chancre), diffuse maculopapular rash.

Muscular dystrophy[36] | \+  | \-  | \-  | \-  | Proximal > Distal  | Systemic  | BL  | Insidious  | Genetic testing  | Muscle biopsy | Progressive proximal lower limb weakness with calf pseudohypertrophy in early childhood. Gower sign positive.
Multiple sclerosis exacerbation[37] | \+  | \+  | \+  | \+  | Generalized  | Systemic  | NL  | Sudden  | ↑CSF IgG levels

(monoclonal)

| Clinical assessment and MRI [38] | Blurry vision, urinary incontinence, fatigue
Amyotrophic lateral sclerosis[39] | \+  | \-  | \-  | \-  | Generalized  | Systemic  | BL  | Insidious  | Normal LP (to rule out DDx)  | MRI & LP | Patient initially presents with upper motor neuron deficit (spasticity) followed by lower motor neuron deficit (flaccidity).
Inflammatory myopathy[40] | \+  | \-  | \-  | \-  | Proximal > Distal  | Systemic  | UL or BL  | Insidious  | Elevated CK & Aldolase | Muscle biopsy | Progressive proximal muscle weakness in 3rd to 5th decade of life. With or without skin manifestations.

## References

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1. ↑ 1.0 1.1 1.2 1.3 Falconer M, Bollenbach E (2000). "Late functional loss in nonparalytic polio". American journal of physical medicine & rehabilitation / Association of Academic Physiatrists. 79 (1): 19–23. PMID 10678598.
2. ↑ 2.0 2.1 2.2 2.3 Sutter RW, Brink EW, Cochi SL, Kew OM, Orenstein WA, Biellik RJ; et al. (1989). "A new epidemiologic and laboratory classification system for paralytic poliomyelitis cases". Am J Public Health. 79 (4): 495–8. PMC 1349984. PMID 2929811.CS1 maint: Explicit use of et al. (link) CS1 maint: Multiple names: authors list (link) CS1 maint: PMC format (link)
3. ↑ 3.0 3.1 3.2 Alcalá H (1993). "[The differential diagnosis of poliomyelitis and other acute flaccid paralyses]". Bol Med Hosp Infant Mex. 50 (2): 136–44. PMID 8442872.
4. ↑ 4.0 4.1 4.2 Asnis DS, Conetta R, Teixeira AA, Waldman G, Sampson BA (2000). "The West Nile Virus outbreak of 1999 in New York: the Flushing Hospital experience". Clin Infect Dis. 30 (3): 413–8. doi:10.1086/313737. PMID 10722421.CS1 maint: Multiple names: authors list (link)
5. ↑ 5.0 5.1 5.2 Campbell, Grant L; Marfin, Anthony A; Lanciotti, Robert S; Gubler, Duane J (2002). "West Nile virus". The Lancet Infectious Diseases. 2 (9): 519–529. doi:10.1016/S1473-3099(02)00368-7. ISSN 1473-3099.
6. ↑ 6.0 6.1 6.2 Moorthi S, Schneider WN, Dombovy ML (1999). "Rehabilitation outcomes in encephalitis--a retrospective study 1990-1997". Brain Inj. 13 (2): 139–46. PMID 10079959.CS1 maint: Multiple names: authors list (link)
7. ↑ 7.0 7.1 "Poliomyelitis".
8. ↑ 8.0 8.1 Kira R (February 2018). "[Acute Flaccid Myelitis]". Brain Nerve (in Japanese). 70 (2): 99–112. doi:10.11477/mf.1416200962. PMID 29433111.CS1 maint: Unrecognized language (link)
9. ↑ Hopkins SE (November 2017). "Acute Flaccid Myelitis: Etiologic Challenges, Diagnostic and Management Considerations". Curr Treat Options Neurol. 19 (12): 48. doi:10.1007/s11940-017-0480-3. PMID 29181601.
10. ↑ Messacar K, Schreiner TL, Van Haren K, Yang M, Glaser CA, Tyler KL, Dominguez SR (September 2016). "Acute flaccid myelitis: A clinical review of US cases 2012-2015". Ann. Neurol. 80 (3): 326–38. doi:10.1002/ana.24730. PMC 5098271. PMID 27422805.
11. ↑ Chong PF, Kira R, Mori H, Okumura A, Torisu H, Yasumoto S, Shimizu H, Fujimoto T, Hanaoka N, Kusunoki S, Takahashi T, Oishi K, Tanaka-Taya K (February 2018). "Clinical Features of Acute Flaccid Myelitis Temporally Associated With an Enterovirus D68 Outbreak: Results of a Nationwide Survey of Acute Flaccid Paralysis in Japan, August-December 2015". Clin. Infect. Dis. 66 (5): 653–664. doi:10.1093/cid/cix860. PMC 5850449. PMID 29028962.
12. ↑ Messacar K, Asturias EJ, Hixon AM, Van Leer-Buter C, Niesters H, Tyler KL, Abzug MJ, Dominguez SR (August 2018). "Enterovirus D68 and acute flaccid myelitis-evaluating the evidence for causality". Lancet Infect Dis. 18 (8): e239–e247. doi:10.1016/S1473-3099(18)30094-X. PMID 29482893. Vancouver style error: initials (help)
13. ↑ Chen IJ, Hu SC, Hung KL, Lo CW (September 2018). "Acute flaccid myelitis associated with enterovirus D68 infection: A case report". Medicine (Baltimore). 97 (36): e11831. doi:10.1097/MD.0000000000011831. PMC 6133480. PMID 30200066.
14. ↑ "Botulism | Botulism | CDC".
15. ↑ McCroskey LM, Hatheway CL (May 1988). "Laboratory findings in four cases of adult botulism suggest colonization of the intestinal tract". J. Clin. Microbiol. 26 (5): 1052–4. PMC 266519. PMID 3290234.
16. ↑ Lindström M, Korkeala H (April 2006). "Laboratory diagnostics of botulism". Clin. Microbiol. Rev. 19 (2): 298–314. doi:10.1128/CMR.19.2.298-314.2006. PMC 1471988. PMID 16614251.
17. ↑ Brook I (2006). "Botulism: the challenge of diagnosis and treatment". Rev Neurol Dis. 3 (4): 182–9. PMID 17224901.
18. ↑ Dimachkie MM, Barohn RJ (May 2013). "Guillain-Barré syndrome and variants". Neurol Clin. 31 (2): 491–510. doi:10.1016/j.ncl.2013.01.005. PMC 3939842. PMID 23642721.
19. ↑ Walling AD, Dickson G (February 2013). "Guillain-Barré syndrome". Am Fam Physician. 87 (3): 191–7. PMID 23418763.
20. ↑ Gilhus NE (2011). "Lambert-eaton myasthenic syndrome; pathogenesis, diagnosis, and therapy". Autoimmune Dis. 2011: 973808. doi:10.4061/2011/973808. PMC 3182560. PMID 21969911.
21. ↑ Krishnan C, Kaplin AI, Deshpande DM, Pardo CA, Kerr DA (May 2004). "Transverse Myelitis: pathogenesis, diagnosis and treatment". Front. Biosci. 9: 1483–99. PMID 14977560.
22. ↑ Amato AA, Greenberg SA (December 2013). "Inflammatory myopathies". Continuum (Minneap Minn). 19 (6 Muscle Disease): 1615–33. doi:10.1212/01.CON.0000440662.26427.bd. PMID 24305450.
23. ↑ 23.0 23.1 Berger JR, Dean D (2014). "Neurosyphilis". Handb Clin Neurol. 121: 1461–72. doi:10.1016/B978-0-7020-4088-7.00098-5. PMID 24365430.
24. ↑ Talukder RK, Sutradhar SR, Rahman KM, Uddin MJ, Akhter H (2011). "Guillian-Barre syndrome". Mymensingh Med J. 20 (4): 748–56. PMID 22081202.CS1 maint: Multiple names: authors list (link)
25. ↑ Merino-Ramírez MÁ, Bolton CF (2016). "Review of the Diagnostic Challenges of Lambert-Eaton Syndrome Revealed Through Three Case Reports". Can J Neurol Sci. 43 (5): 635–47. doi:10.1017/cjn.2016.268. PMID 27412406.
26. ↑ Gilhus NE (2016). "Myasthenia Gravis". N Engl J Med. 375 (26): 2570–2581. doi:10.1056/NEJMra1602678. PMID 28029925.
27. ↑ Ozono K (2016). "[Diagnostic criteria for vitamin D-deficient rickets and hypocalcemia-]". Clin Calcium. 26 (2): 215–22. doi:CliCa1602215222 Check `|doi=` value (help). PMID 26813501.
28. ↑ Kamanyire R, Karalliedde L (2004). "Organophosphate toxicity and occupational exposure". Occup Med (Lond). 54 (2): 69–75. PMID 15020723.
29. ↑ Pecina CA (2012). "Tick paralysis". Semin Neurol. 32 (5): 531–2. doi:10.1055/s-0033-1334474. PMID 23677663.
30. ↑ Bane V, Lehane M, Dikshit M, O'Riordan A, Furey A (2014). "Tetrodotoxin: chemistry, toxicity, source, distribution and detection". Toxins (Basel). 6 (2): 693–755. doi:10.3390/toxins6020693. PMC 3942760. PMID 24566728.CS1 maint: Multiple names: authors list (link)
31. ↑ Kuntzer T, Hirt L, Bogousslavsky J (1996). "[Neuromuscular involvement and cerebrovascular accidents]". Rev Med Suisse Romande. 116 (8): 605–9. PMID 8848683.CS1 maint: Multiple names: authors list (link)
32. ↑ Laffont I, Julia M, Tiffreau V, Yelnik A, Herisson C, Pelissier J (2010). "Aging and sequelae of poliomyelitis". Ann Phys Rehabil Med. 53 (1): 24–33. doi:10.1016/j.rehab.2009.10.002. PMID 19944665.CS1 maint: Multiple names: authors list (link)
33. ↑ West TW (2013). "Transverse myelitis--a review of the presentation, diagnosis, and initial management". Discov Med. 16 (88): 167–77. PMID 24099672.
34. ↑ Liu LL, Zheng WH, Tong ML, Liu GL, Zhang HL, Fu ZG; et al. (2012). "Ischemic stroke as a primary symptom of neurosyphilis among HIV-negative emergency patients". J Neurol Sci. 317 (1–2): 35–9. doi:10.1016/j.jns.2012.03.003. PMID 22482824.CS1 maint: Explicit use of et al. (link) CS1 maint: Multiple names: authors list (link)
35. ↑ Ho EL, Marra CM (2012). "Treponemal tests for neurosyphilis--less accurate than what we thought?". Sex Transm Dis. 39 (4): 298–9. doi:10.1097/OLQ.0b013e31824ee574. PMC 3746559. PMID 22421697.
36. ↑ Falzarano MS, Scotton C, Passarelli C, Ferlini A (2015). "Duchenne Muscular Dystrophy: From Diagnosis to Therapy". Molecules. 20 (10): 18168–84. doi:10.3390/molecules201018168. PMID 26457695.CS1 maint: Multiple names: authors list (link)
37. ↑ Filippi M, Preziosa P, Rocca MA (2016). "Multiple sclerosis". Handb Clin Neurol. 135: 399–423. doi:10.1016/B978-0-444-53485-9.00020-9. PMID 27432676.CS1 maint: Multiple names: authors list (link)
38. ↑ Giang DW, Grow VM, Mooney C, Mushlin AI, Goodman AD, Mattson DH; et al. (1994). "Clinical diagnosis of multiple sclerosis. The impact of magnetic resonance imaging and ancillary testing. Rochester-Toronto Magnetic Resonance Study Group". Arch Neurol. 51 (1): 61–6. PMID 8274111.CS1 maint: Explicit use of et al. (link) CS1 maint: Multiple names: authors list (link)
39. ↑ Riva N, Agosta F, Lunetta C, Filippi M, Quattrini A (2016). "Recent advances in amyotrophic lateral sclerosis". J Neurol. 263 (6): 1241–54. doi:10.1007/s00415-016-8091-6. PMC 4893385. PMID 27025851.CS1 maint: Multiple names: authors list (link)
40. ↑ Michelle EH, Mammen AL (2015). "Myositis Mimics". Curr Rheumatol Rep. 17 (10): 63. doi:10.1007/s11926-015-0541-0. PMID 26290112.

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