Acute Flaccid Myelitis is a polio-like illness that tends to start with symptoms of an upper respiratory tract illness and leads to flaccid paralysis.  There are more questions than there are answers, but Dr. Uzma Hasan, pediatric infectious disease specialist, walks us through what we do know so we can all be better prepared if we encounter this illness.

EPISODE TRANSCRIPT

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Unknown Speaker  0:03
Welcome to the physicians guide to doctoring A Practical Guide for practicing physicians where Dr. Bradley Block interviews experts in and out of medicine to find out everything we should have learned while we were memorizing the Krebs cycle. The ideas expressed on this podcast are those of the interviewer and interviewee and do not represent those of their respective employers. This podcast is intended for medical professionals. The information is to be used in the context of your own clinical judgment. And those on this podcast accept no liability for the outcomes of medical decisions based on this information, as the radiologist like to say clinical correlation is required. This is not medical advice. And even though the magic of podcasting may make it seem like we’re speaking directly in your ears, this does not constitute a physician patient relationship. If you have a medical problem, seek medical attention
Unknown Speaker  1:00
On today’s episode we discussed the cute placid, my lightest, the polio like illness that has been in the news lately with infectious disease specialist, Dr. Umar Hassan to talk about what the cause may be, how it presents some of the workup management strategies, and current research with hope for the future.
Unknown Speaker  1:19
Welcome back to the physicians guide to doctoring. On today’s episode, we have Dr. Uzma Hassan. She’s a double boarded physician board in pediatrics and pediatric infectious disease and is currently the division head for pediatric infectious disease at St. Barnabas Hospital in New Jersey. Dr. son was willing to do this on short notice given the recent increase in episodes of acute flaccid, my lightest, so that’s what we’re going to talk about today. One of the functions of this podcast is to educate physicians about current events. And given the recent spike in cases. I think it’s important for physicians who see this and don’t see this necessarily To be familiar with it, because, as an outlier geologist, I’m not likely to see this, but that doesn’t mean that I won’t get questions from family, friends and possibly patients. So Dr. Khan was educated in medical school at the Agha Khan University, went on to residency at the Cleveland Clinic and completed her infectious disease fellowship at Northwestern and is currently like I said the division head of infectious disease at St. Barnabas Hospital in Jersey. So, Dr. Hassan, thank you so much for taking the time to speak with us today.
Unknown Speaker  2:31
Thank you so much for having me. So,
Unknown Speaker  2:34
as an old alarm geologist, it’s not likely that I’m going to see this but as a doctor, people might be asking asking me about it. So can you just give us some basics about what is acute flaccid mellitus?
Unknown Speaker  2:48
Yes, sure. So to placid my light is is actually a very rare illness or reported about one 1 million young adults and children and it is characterized by rapid onset of weakness or paralysis of one or more limbs. And usually these children or adults a wind up having some abnormality in their gray matter when we do imaging with MRI. Some of these children can present with grouping of their eyelids having some difficulty speaking, they can present with the facial group. And most of these patients will have an acute wireless illness with you know, running those upper respiratory infections symptom, sometimes gastrointestinal symptoms about a week prior to the onset of this paralysis.
Unknown Speaker  3:43
So it can affect a cranial nerve or a peripheral nerve. That’s correct. Does it usually affect a singular nerve or can it can it affect a number of nerves
Unknown Speaker  3:55
typically, the involvement is is mostly seen and in spinal cord is fixed multiple segments of the spinal cord at the same time. In the cases that be seen for some reason, the cervical part of the spinal cord seems to be involved more often, which means that some of these patients might end up with respiratory issues. That’s exactly right.
Unknown Speaker  4:17
Oh, so I thought as a little oncologist, I wouldn’t be seeing it. But if it’s a respiratory issue, sometimes they’ll call us for things like that, especially if someone is has been on a ventilator for a while and needs a tracheostomy. So so if you are let’s say, you’re someone who’s who’s more likely to see this initially like a pediatrician, a neurologist, infectious disease intensive lyst emergency medicine physician, how does this what what are some signs that will that should make this part of my differential?
Unknown Speaker  4:54
Very good question. So you know, most of the children who present with this illness will Have a proceeding illness or an upper respiratory infection, and then they will come in with a sudden onset of weakness of an arm or leg. They complain of a feeling of heaviness or being unable to move that extremity. And I think the key thing is that too, not to dismiss those symptoms, but to take them very seriously. Yeah, a lot of times, you know, children this age group will be labeled as feigning illness. And and I think the key thing to recognize is that this is a real entity. If we start seeing the child who is not wanting to move and extremity that, and especially in the context of a recent viral syndrome, we have to take that very seriously.
Unknown Speaker  5:45
So what in particular Am I looking for on it on exam? Right, are there any particular parts before we get into diagnostic tests?
Unknown Speaker  5:53
Yes, I think there’s a couple of things that you will see in the extremity is significant muscle weakness. The children that we have seen will not be able to move there will be involved arm or leg at all You will see absence of reflexes in that extremity. And typically you know you do not see any sensory symptoms. So they will not typically complain of tingling, or of your temptation and their extremity. Typically they have internet sensation, but the ability to move that extremity is what gets compromised. Is there anything that we might confuse this for? Yes, there’s a bunch of things that can can mimic acute facet my latest. Some of these children get evaluated for things like Jamboree, or Crohn’s or smile lighters. They can be evaluated for peripheral neuropathy or so. So there’s a bunch of things that can mimic q classic, my latest I think the key distinction distinguishing feature is what we find on imaging, as well as some of the CSR findings. To help us sort of weigh in on the diagnosis So, the CDC had has now classified attracted by lightest, the the group the cases as probable cases versus confirmed cases. The probable cases are labeled based on their spinal fluid finding in in the context of a child who has an exam that’s abnormal or paralysis of an extremity. If you see spinal fluid parasitosis, which means a white cell count of more than five on the spinal fluid. We label that as a probable case, and a confirmed case is when they have truly have abnormality of their gray matter on an MRI, and they are presenting with involvement of, you know, a vocal paralysis of a limb or so so that’s a confirmed case. What do we think is causing this? So you know, there’s been several viruses that have been previously implicated with to trusted my light is enterovirus. The 68 was implicated in the outbreak in 2014. And usually it’s the non polio, enteroviruses that sort of take the lead amongst other viruses that have been implicated in cases of the future acid. My light is there is the non polio enteroviruses, like I mentioned. Then there has been some cases described with Admiral virus. Some some cases described the herpes zoster with rabies, or so so, so but most commonly, it’s the non polio ankle viruses that have been implicated in cases of a to class of my lightest.
Unknown Speaker  8:38
Wow, that’s interesting because that’s something that’s been implicated in vestibular neuritis. Yes. Yeah. So, so, there there are some parallels are interesting. And what can we do for this what what is the house of medicine have for these patients?
Unknown Speaker  8:58
So, so amongst a limited number of cases that we have seen over the years or so, there’s been a bunch of modalities of treatment that have been tried patients have been given IBM, you know, globulin. They have been plasma for research has been tried in some cases or so, and, and variable outcomes. Pretty much treatment is done on a case by case basis and there’s really no data to back up one treatment versus another. The CDC and advisors use a use of steroids with caution in cases of a non political or non fully enterovirus related to class in my life. So, so steroids youth has been pretty much reserved as the cases that are really severe who have who have been a front acknowledge or recipe involvement, which is where we have used steroids but again advised caution with the use of steroids in this case scenario. Is it communicable
Unknown Speaker  10:02
because if it’s a virus, right, you shouldn’t you shouldn’t be seeing it in in clusters. But I don’t think of vestibular neuritis or Labyrinth itis as something that’s communicable right? You never see that spread through a household where every family member comes in at the same time with vertigo. It’s like it’s an isolated incident. So, very good question. Typically this disease is sort of confined to the host in which it is happening in. So you do not see clusters happening in the household or multiple memory family members of a household getting infected.
Unknown Speaker  10:35
So presumably though the virus was contagious, so you might have seen a bunch of family members get a cold at the same time but only one one person ends up with AFM. That’s it. That’s exactly right. The that you may see a symptomatic infection or you may see a milder form of infection and the other members in the household and you may have another household member wind up with a FM
Unknown Speaker  11:00
You have that’s been described where you’ll have more than one family member household member with with this?
Unknown Speaker  11:08
No, actually not. Typically, you will see a symptomatic illness and other household members. But you you will, you will it is typically just one member of the household who’s been who’s been symptomatic with AFM. There’s not been a cluster of AFM cases described in one one household
Unknown Speaker  11:26
focus. Okay, I misunderstood and so what what do we tell parents family members? If they’re if they’re concerned that you know, oh, my my child was exposed there was a kid in their class. Now you know, he’s my, my son has a runny nose. I’m worried that he’s going to develop AFM how what what can we say to those parents?
Unknown Speaker  11:53
I think the key message to get across is this is exceedingly rare and and you know, like Like the CDC discusses less than one in a million cases or so the and probably fewer related issues are much more common, or flu related deaths are much more common than you would see and a child having enterovirus related AFM. So I think it’s a constant reminder that that even though this is Block media attention, I think that there are other things that are that are bigger troublemakers than AFM is.
Unknown Speaker  12:30
That’s a great point actually, that this is an excellent teaching opportunity. So you have an anxious parent that comes in with a child with a with what seems like a cold and making sure that that child and the parent has both of both had their flu shot because that is is more likely to be problematic for them for something that’s that’s exceedingly rare like like FM. Are you familiar with any research That, that’s being done right now that might give us some, some hope for some more effective management strategies.
Unknown Speaker  13:07
Yeah, so a couple of things that are in the works. One is the CDC has has come up with has sort of following these patients long term. So so all the patients and from each state that gets a group ordered out there collecting specimens, identifying, you know, commonalities in between these patients, and then these children will get cracked long term to see how they recover. Interestingly, there has been some great research out of Children’s Hospital LA, were there the good looked at North comfort in the kids with AFM, who had persistent weakness. So depending on where they had involvement, they were offered surgery if they had Dr. paralysis, they were offered surgery actually of the five to six month mark. If they had one focal lemon movement, for example, a shoulder or elbow they would due north conference with them at the six to nine month mark and then if they had isolated one muscle involvement they did they did it around a year out from their initial presentation and their initial results are actually very promising. The has had some children who had significant than moment wars is now starting to still show some recovery and in muscle function and the children who’ve had these North conference done so I think that this is extremely promising. I also know that the Children’s Hospital of Philadelphia is taking this up. And and I think in the children who have extreme compromised and and lack of improvement, or lack of significant improvement, this is a very, very promising
Unknown Speaker  14:49
opportunity or promising
Unknown Speaker  14:53
method of treatment that’s out there and and something to do look for in the future business. How the Quran fair in the long run.
Unknown Speaker  15:04
That’s interesting that you that you brought this up that this is being done at Children’s Hospital in LA, because one of the guys doing this was a resident with me at Georgetown. I didn’t have residency at Georgetown and he was a plastic surgery resident. And I think he’s been actually featured on the news and he’s been posting on his Facebook page about this. Mitchell Surya SERUYA. So I’ll find out from him if we can post post a link to his department, so Children’s Hospital. So if you have a patient or you know somebody that has a compromised limb from AFM, it sounds like get them in touch with I guess it would be the plastic surgery department at CHOP or at Children’s Hospital la because there’s some there’s some promising work being done on on nerve transfers. Wow.
Unknown Speaker  16:01
That’s that’s, that’s amazing. That’s amazing that they’re doing these things.
Unknown Speaker  16:06
Are there any other questions that you’re getting from family member from from families or from other physicians that you think we haven’t covered yet?
Unknown Speaker  16:16
Yeah, I think the one other thing that they people ask is about the 60 of the flu vaccine in the context of these viral illnesses or so. You know, I always say that that flu is entirely if the children were vaccinated against flu, even if they were to have you in that season, they get a much more attenuated for both the illness so absolutely must be vaccinated. I think that’s the only doctor going to provide them with the additional level of protection. And and, and that’s the question that we get asked regarding regarding the FM patients. So far BB amongst the Colorado cluster, We had in 2014, you know, from my understanding from the CDC folks is that all of those children were vaccinated against the flu and they did. Absolutely fine. So though the CDC actually even advocates for vaccination in this population, and and that’s just something to put out there.
Unknown Speaker  17:19
Oh, yeah. I can’t imagine if if one of them had respiratory compromised, and then were to develop influenza that that would be horrible.
Unknown Speaker  17:27
Exactly. Wow.
Unknown Speaker  17:29
Well, this this has been extremely informative. I really appreciate you taking the time out of your, your busy day, which was so busy that you actually had a meeting this morning about this illness and and about your patients. Because this is such a such a relevant, relevant illness. Um, one more thing actually, that comes to mind. You mentioned that Colorado cluster in 2014. And part of my research for this podcast I listen to another podcast. where that was recorded in 2016. So there seems to be
Unknown Speaker  18:04
a pattern there. That’s exactly right. Would they have noticed is that we have a biannual peak to this illness. It looks like that. In 2014, there were about 120 confirmed cases in 3034 states. Between the timeframe from August to December, the following year 2015, there were just 22 confirmed cases in 17 states 2016, we saw rise again 149 confirmed cases in 39 states. And in 2017, we had a drop down to 33 cases in 16 states and 2018. Again, we’re back up so there are 62 confirmed cases in 22 states 155 case reports which are sort of pending confirmation from the CDC. So you’re absolutely right, we see a sort of a biennial pattern to the subtler
Unknown Speaker  19:00
Interesting, but but as you were saying, the likelihood of getting it one in a million
Unknown Speaker  19:07
influenza much higher. So when you do have parents that are bringing their children in, and you know, parents, we’re talking we’re just talking about children. What was the age group that’s affected by this?
Unknown Speaker  19:17
Very good question. The average age group for this year’s cluster has been around for years. We have seen a ages up to 17 years being reported out.
Unknown Speaker  19:30
or so but the it’s usually the younger age group that gets affected. Interesting. It’s almost it’s almost as if the illness knows what our cutoff is for what’s considered an adult. It’s gone up to 70. No reported, no reported 18 year olds. Well, exactly right. Dr. Hassan again, I really appreciate you taking the time out, making the excellent point that this is a good segue when a patient brings this up or a parent bring this up to make sure that they’re vaccinated for influenza. And giving us some some great clinical details on what we should keep in mind to look out for this and to educate our peers. So, thank you so much for taking the time. been very informative.
Unknown Speaker  20:11
pleasure. Thank you so much for having me.
Unknown Speaker  20:15
That was Dr. Bradley Block at the physicians guide to doctoring. Find all previous episodes on iTunes, Stitcher, Google podcasts, or wherever you get your podcasts and write us a review. You can also visit us on facebook@facebook.com slash physicians guide to doctoring. If you are interested in being a guest or have a question for a prior guest send a message or post a comment.
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