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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief:  João André Alves Silva, M.D. [2]Gurmandeep Singh Sandhu,M.B.B.S.[3]

## Overview

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The word poliomyelitis is derived from the Greek, where polio means grey and the work myelin means the marrow referring to the spinal cord. Polio myelitis primarily affects the spinal cord in turn leading to the manifestations. Poliovirus is a member of the enterovirus subgroup, family Picornaviridae. Poliovirus is primarily spread from the stools of the infected person and enters the body orally through contaminated water or food (feco-oral transmission), infecting the cells of the gastrointestinal tract, from the mouth to the ileum and mesentrium. After replication, the virus may either be secreted in feces, contributing to the transmission of the disease, or reach the bloodstream, and be transported to other cells of the body, such as those of the reticuloendothelial system. Although the precise mechanism of infection of CNS is not fully understood, the most supported hypothesis is the retrograde axonal transport, according to which the virus enters the axoplasm of a motor neuron, travels to its cell body, where it replicates, and leads to neuron death. In the CNS, poliovirus shows tropism for cells of the anterior horn of the spinal cord, hypothalamus, thalamus, cerebellar vermis, vestibular and deep cerebral nuclei. Death of the motor neuron is responsible for the paralysis often seen in poliomyelitis.

## Case Definitions of Polio

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CDC has given a case definition of paralytic poliomyelitis for surveillance purposes

* “Acute onset of flaccid paralysis of one or more limbs with decreased or absent tendon reflex in the affected limbs, without other apparent causes, and without sensory or cognitive loss.”.[1]
* A confirmed case requires persistence of neurological deficit for 60 days after the onset of the initial symptoms, fatal illness, or unknown follow-up status.[1]

WHO case definition for a suspected case of poliomyelitis is:

* A suspected case is defined as a child under 15 years of age presenting with acute flaccid paralysis (AFP), or as any person at any age with paralytic illness if poliomyelitis is suspected[2]

## Pathophysiology

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### Transmission

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Poliovirus is mostly transmitted through the fecal-oral route, by ingestion of contaminated food or water. In some instances, the oral-oral route may be relevant through pharyngeal secretions. [3][4] Poliomyelitis is highly contagious and spreads easily through human-to-human contact.[5] In endemic areas, wild polioviruses can infect virtually the entire human population.[6] Viral particles are excreted in the feces for several weeks, after initial infection. Although the virus can cross the placenta during pregnancy, the fetus does not appear to be affected by either maternal infection, or polio vaccination.[7] Maternal antibodies can also cross the placenta, providing passive immunity that protects the infant from polio infection during the first few months of life.[8]

Poliovirus enters the body orally and most often infects nearby cells, such as those of the mouth, nose, and throat. Poliovirus commonly targets specific tissues in the CNS such as:[9]

* Anterior horn cells of the spinal cord (in severe cases of the disease, the intermediate, intermediolateral and posterior gray columns may also be affected)
* Hypothalamus
* Thalamus
* Vestibular nuclei
* Deep cerebral nuclei
* Reticular formation
* Cerebellar vermis

### Pathogenesis

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It infects cells by binding to an immunoglobulin-like receptor known as CD155 on the cell surface. The most common course of infection is the replication of poliovirus in cells of the gastrointestinal tract, followed by viral shedding in feces. The specific cells of the gastrointestinal tract, where poliovirus replicates, are not known, however, the virus was successfully isolated from lymphatic cells of the GI tract, including:[9]. Viral particles have been seen in:

* Tonsillar cells
* Peyer's patches of the ileum
* Lymph nodes of the mesenterium

The virus enters the bloodstream and migrates to the reticuloendothelial cells across the body. Poliovirus is able to reach the central nervous system in a small fraction of the symptomatic patients.[9] Not only is the disease not a phase of the viral replication cycle, it also does not benefit the virus in any way. The molecular mechanism behind this disease process is not known.[9]

Poliovirus replicates inside monocytes, which allows for secondary hematogenous spread. The pathological mechanism responsible for the clinical manifestations of CNS poliomyelitis is characterized by selective destruction of motor neurons. Depending of the involved site, motor neuron loss may lead to focal or generalized symptoms. Most commonly observed signs and symptoms include asymmetric limb paralysis in spinal polio and respiratory disturbance with cranial nerve defects in bulbar polio.

Although the mechanism of viral spread to the CNS is not fully understood, two main hypotheses have been proposed:[9]

1. Poliovirus diffuses directly through the blood brain barrier from the bloodstream to the CNS, regardless of cellular receptors.
2. Poliovirus is transported from the peripheral muscles to the brain and spinal cord, through retrograde axonal transport. This hypothesis has been experimentally proven in mice, after CD155 transformation.

Several recent findings supporting the retrograde axonal transport hypothesis have been reported:[9].

*     * Detection of axonal poliovirus in patients with poliomyelitis.
* Interruption of a nerve connection between a site of multiple intramuscular injections and the spinal cord in mice with poliovirus viremia led to improved clinical course of infection. This supports the provocation poliomyelitis hypothesis which states that muscle injury in patients with poliovirus viremia triggers retrograde axonal transport of the virus. This phenomenon is seen in children receiving intramuscular vaccines in areas endemic for poliovirus.[10]
* In mice genetically transformed to express CD155, injection of poliovirus in the left limb led to viral detection in the left anterior horn of the spinal cord only. When the sciatic nerve was promptly sectioned after injection of the virus, the risk of paralysis in the injected limb was greatly reduced.
* Bulbar poliomyelitis following tonsillectomy may possibly be explained by the previously described mechanisms.
* Overexpression of CD155 in the muscle fibers of patients with paralytic poliomyelitis. To note, CD155 directly interacts with the dynein retrograde complex through Tctex-1.[9]

The main explanation for increased susceptibility to retrograde axonal transport of poliovirus in areas of injured muscle has been explained. In a neuronal synapse, the rate of endocytosis is related to the level of neuron activity. Correspondingly, for a motor neuron, the level of neuron activity and rate of endocytosis at the neuromuscular junction is related to the extent of muscle contraction. This explains the connection between extreme exercise or muscle injury and development of poliomyelitis in patients with viremia. Also, since most of CD155 receptors are transported back to the cell body, the virus is carried along, supporting the retrograde transport hypothesis.[9]

Once at the cell body of the neuron, the change from axoplasm to cytoplasm is thought to interfere with the stability of the viral coat, leading to the exposure of the viral RNA. Viral replication interferes with neuron stability, killing the motor neuron. Death of a motor neuron paralyzes the respective muscle fiber.

### Course of Disease

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The pre- paralytic or non-paralytic course of the disease includes:-[11]

* Headache
* Pharyngitis
* Myalgia
* Anorexia
* Nausea
* Vomiting

In non- paralytic illness, the symptoms go away within one or two weeks.

Paralytic Poliomyelitis: [11] After the meningitis phase, the spinal form of poliomyelitis occurs which consists of:

* Muscle pain
* Muscle spasms
* Fasciculations

Weakness is asymmetrical affecting the lower limbs more than the upper limbs. The weakness usually becomes maximum within 48hrs, especially in children. In some, the weakness may further increase after a period of stability but no further weakness occurs once the fever subsides. Muscle tone is flaccid and the reflexes are absent along with paraesthesia. Any cranial nerve may be involved but most frequently leads to dysphasia, dysphasia, and respiratory failure[12]. Vasomotor involvement such as hypertension, hypotension, and circulatory collapse lead to mortality in patients.

Bulbar form:[13] Seen more in children in which tonsils and adenoids have been removed.

## Vaccine mediated polio infection

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Oral polio vaccine (OPV) is one of the safest and most effective vaccination programs that prevented millions of cases of polio not only through direct immunization but also through herd immunity. In rare occasions, the vaccine is associated with paralytic polio. There are two subtypes of paralytic polio related to OPV vaccine: vaccine associated paralytic polio and vaccine derived paralytic polio.

### Vaccine associated paralytic polio

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* Vaccine associated paralytic polio (VAPP) occurs when the attenuated strain used in the vaccine reverts inside the intestine into more virulent form.[2][14][15]
* The more virulent form is capable of causing the disease only in the vaccinated child or a close susceptible contact. Therfore, no outbreaks are associated with VAPP.
* The prevalence of (VAPP) is 1 in 2.7 million doses of the vaccine.
* In developed countries, the risk of VAPP is increased with the first dose of the vaccine while in developed countries, It’s increased with subsequent doses.

### Vaccine derived paralytic polio

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* Vaccine derived paralytic polio (VDPP) is caused by very rare mutation of the original strain of polio in the vaccine.[2][16]
* VDPP has the ability to cause the disease in any non immune person whether the vaccinated person or a contact, therefore it has the ability to cause outbreaks or even epidemics especially in communities that are not properly covered with the vaccination program.
* When it causes outbreaks, VDPP is called circulating vaccine derived paralytic polio (cVDPP).
* In the last 10 years, 24 VDPP reported outbreaks happened in 21 countries causing 750 cases of paralytic polio.
* The management of VDPP is conducting extensive vaccination campaigns in the affected community aiming for vaccinating every child and thus preventing the spread of the infection.

## Microscopic Pathology Images

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* A photomicrograph of skeletal muscle tissue revealing myotonic dystrophic changes as a result of Polio Type III.Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.[17]

* A photomicrograph of the lumbar spinal cord depicting an infarct due to Polio Type III surrounding the anterior spinal artery.Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.[17]

* A photomicrograph of the lumbar spinal cord depicting an infarct due to Polio Type III surrounding the anterior spinal artery.Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.[17]

* A photomicrograph of the lumbar spinal cord depicting degenerative changes due to an infarct caused by Polio Type III.Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.[17]

* A photomicrograph of the thoracic spinal cord depicting degenerative changes due to Polio Type III.Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.[17]

* A photomicrograph of the thoracic spinal cord depicting degenerative changes due to Polio Type III.Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.[17]

* A photomicrograph of the cervical spinal cord in the region of the anterior horn revealing Polio Type III degenerative changes.Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.[17]

* A photomicrograph of the cervical spinal cord in the region of the anterior horn revealing Polio Type III degenerative changes.Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.[17]

* A photomicrograph of the cervical spinal cord in the region of the anterior horn revealing Polio Type III degenerative changes.Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.[17]

* Under a low magnification, this photomicrograph of pontine tissue at the level of abducens nucleus reveals histopathologic changes in a poliomyelitis patient.Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.[17]

* Photomicrograph of the Cervical Spinal Cord Affected by Polio Type III VirusAdapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.[17]

## References

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1. ↑ 1.0 1.1 "Poliomyelitis, Paralytic | 2010 Case Definition".
2. ↑ 2.0 2.1 2.2 "www.who.int" (PDF).
3. ↑ Nathanson N, Kew OM (2010). "From emergence to eradication: the epidemiology of poliomyelitis deconstructed". Am J Epidemiol. 172 (11): 1213–29. doi:10.1093/aje/kwq320. PMC 2991634. PMID 20978089.CS1 maint: PMC format (link)
4. ↑ "Poliomyelitis".
5. ↑ Kew O, Sutter R, de Gourville E, Dowdle W, Pallansch M (2005). "Vaccine-derived polioviruses and the endgame strategy for global polio eradication". Annu Rev Microbiol. 59: 587–635. PMID 16153180.CS1 maint: Multiple names: authors list (link)
6. ↑ Parker SP (ed.) (1998). McGraw-Hill Concise Encyclopedia of Science & Technology. New York: McGraw-Hill. p. 67\. ISBN 0-07-052659-1.CS1 maint: Extra text: authors list (link)
7. ↑ Joint Committee on Vaccination and Immunisation (Salisbury A, Ramsay M, Noakes K (eds.) (2006). Chapter 26:Poliomyelitis. in: Immunisation Against Infectious Disease, 2006 (PDF). Edinburgh: Stationery Office. pp. 313–29. ISBN 0-11-322528-8.CS1 maint: Multiple names: authors list (link) CS1 maint: Extra text: authors list (link)
8. ↑ Sauerbrei A, Groh A, Bischoff A, Prager J, Wutzler P (2002). "Antibodies against vaccine-preventable diseases in pregnant women and their offspring in the eastern part of Germany". Med Microbiol Immunol. 190 (4): 167–72. PMID 12005329.CS1 maint: Multiple names: authors list (link)
9. ↑ 9.0 9.1 9.2 9.3 9.4 9.5 9.6 9.7 Mueller S, Wimmer E, Cello J (2005). "Poliovirus and poliomyelitis: a tale of guts, brains, and an accidental event". Virus Res. 111 (2): 175–93. doi:10.1016/j.virusres.2005.04.008. PMID 15885840.CS1 maint: Multiple names: authors list (link)
10. ↑ Gromeier M, Wimmer E (1998). "Mechanism of injury-provoked poliomyelitis". J Virol. 72 (6): 5056–60. PMC 110068. PMID 9573275.CS1 maint: PMC format (link)
11. ↑ 11.0 11.1 Schmoldt A, Benthe HF, Haberland G (1975). "Digitoxin metabolism by rat liver microsomes". Biochem Pharmacol. 24 (17): 1639–41. PMID https://dx.doi.org/10.1136/pgmj.72.853.641 Check `|pmid=` value (help).CS1 maint: Multiple names: authors list (link)
12. ↑ PLUM F, SWANSON AG (1959). "Central neurogenic hyperventilation in man". AMA Arch Neurol Psychiatry. 81 (5): 535–49. doi:10.1001/archneurpsyc.1959.02340170001001. PMID 13636523.
13. ↑ ANDERSON GW, RONDEAU JL (1954). "Absence of tonsils as a factor in the development of bulbar poliomyelitis". J Am Med Assoc. 155 (13): 1123–30. doi:10.1001/jama.1954.03690310001001. PMID 13174358.
14. ↑ Nkowane BM, Wassilak SG, Orenstein WA, Bart KJ, Schonberger LB, Hinman AR, Kew OM (1987). "Vaccine-associated paralytic poliomyelitis. United States: 1973 through 1984". JAMA. 257 (10): 1335–40. PMID 3029445.
15. ↑ Sullivan AA, Boyle RS, Whitby RM (1995). "Vaccine-associated paralytic poliomyelitis". Med. J. Aust. 163 (8): 423–4. PMID 7476613.
16. ↑ Khetsuriani N, Prevots DR, Quick L, Elder ME, Pallansch M, Kew O, Sutter RW (2003). "Persistence of vaccine-derived polioviruses among immunodeficient persons with vaccine-associated paralytic poliomyelitis". J. Infect. Dis. 188 (12): 1845–52. doi:10.1086/379791. PMID 14673763.
17. ↑ 17.00 17.01 17.02 17.03 17.04 17.05 17.06 17.07 17.08 17.09 17.10 "Public Health Image Library (PHIL), Centers for Disease Control and Prevention".

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