Question

A missionary couple, living in West Africa, bring their 4-year old son to the office of their physician on the second day of a visit home to Minnesota. The boy had a mild episode of diarrhea about seven days earlier and would not eat. He seemed to recover, but the mother noticed that the boy was having trouble walking the previous night and had seemed to have trouble dressing himself and walking that day.

On examination, the patient had no significant fever (98.9) and normal bowel sounds. His chest, ears and eyes were clear. He had no rebound tenderness in the abdomen. The physician noted that the child had poor muscular reflexes in his arms and legs. The child also was a bit lethargic and seemed confused.

The family lives in an isolated village in Africa. The mother opposes vaccinations on personal grounds, so the child has only had the initial series of DPT shots and no other typical vaccines. The village where they live has many problems with parasites and insect borne fevers (including Dengue).

Urine, stool and blood samples were collected for analysis.

1) This disease is most likely:

• an intestinal infection or parasite.
• a respiratory infection or parasite.
• a neurological infection or parasite.
• a urinary tract infection or parasite.
• Not enough information is given to determine this.

2) Your best guess at a diagnosis is:

• Hib meningitis
• sleeping sickness
• polio
• a parasitic worm
• malaria

3) Which of the following samples could easily provide confirmation of your diagnosis?

• The stool would show the presence of the worms.
• The serum would have antibody against polio.
• The urine would contain H. influenzae organisms.
• The blood would contain red blood cells with malarial parasites.
• Only CSF will show the answer.

4) Would receiving the childhood vaccine series have prevented this problem?

• yes, without doubt
• yes, most likely
• possibly, but living in Africa the pathogen load might be too high
• no, no vaccine is normally given
• no way, no vaccine exist

Answer 1

1)a neurological infection or parasite.

The physician noted that the child had

• Trouble dressing himself and walking.
• Poor muscular reflexes in his arms and legs.
• The child also was a bit lethargic and seemed confused.
• trouble dressing himself and walking.

From these symptoms it is evident that central nervous system involvement- may be poliomyelitis.

Polio myelitis. Poliomyelitis is an acute viral infection caused by an RNA virus.

It is primarily an infection of the human alimentary tract but the virus may infect the central nervous system in a small percentage (about one percentage) resulting in various degrees of paralysis.

Immunization is the sole effective means of polio myelitis.

The virus is transmitted by the fecooral route through ingestion and multiply initially in the gastrointestinal epithelium later carried to spinal cord and brain. In the central nervous system virus multiply selectively in the neurons and destroy them.

2) Polio myelitis

The child is not vaccinated except DPT

DPT Poor muscular reflexes in his arms and legs.

The child also was a bit lethargic and seemed confused.

trouble dressing himself and walking

From the symptoms the child has developed paralytic polio in which the virus invade CNS and causes varying degree of paralysis.The predominant sign is asymmetrical paralysis and is not progressive paralysis also.

Other choices

Rule out hib meningitis, as typical meningitis symptoms - stiff neck and dislike of bright light.

Progressive paralysis usually indicate a case other than polio.

African sleeping sickness caused by trypanosoma due to the bite og tsetse fly.

Signs and symptoms

fever, swollen lymph glands, aching muscles and joints, headaches and irritability.

In advanced stages, the disease attacks the central nervous system and people present with changes in personality, alteration of the difficulty in walking and talking.

Here the child has flacid paralysis evidenced by impaired muscle reflex in arms and legs.

Malaria and parasitic worms do not cause david paralysis.

3. The serum would have antibody against polio.

Virus isolation in the tissue culture is the best method for specific diagnosis.Many specimens can be used including blood, CSF,throat swab and CSF.

4. Yes without doubt

Immunization is the sole effective means of preventing poliomyelitis.

Both killed and live atteunated vaccines are available and both are safe and effective when used correctly.

It is essential to immunize all infants by 6 months of age to protect them against polio.