Skip directly to site content Skip directly to page options Skip directly to A-Z link Skip directly to A-Z link Skip directly to A-Z link
Volume 19, Number 9—September 2013

Detection of Diphtheritic Polyneuropathy by Acute Flaccid Paralysis Surveillance, India

Farrah J. Mateen1Comments to Author , Sunil Bahl, Ajay Khera, and Roland W. Sutter
Author affiliations: Johns Hopkins University, Baltimore, Maryland, USA (F.J. Mateen); World Health Organization, Geneva, Switzerland (F.J. Mateen, R.W. Sutter); World Health Organization National Polio Surveillance Project, New Delhi, India (S. Bahl); Ministry of Health and Family Welfare, New Delhi (A. Khera)

Main Article

Table 1

Clinical characteristics of 15 children with diphtheritic polyneuropathy, India, 2007–2011*

Patient Age, y/sex Paralysis description (worst motor power) Tones/reflexes Fever at onset Neck swelling Other symptoms of diphtheria CSF/NCS Respiratory involvement GBS disability score Outcome at 60-d follow-up (no. days death occurred postparalysis onset)
1 5/F Symmetric limb weakness (NA) NA N N Throat pain, nasal regurgitation, nasal intonation, and twang with speech NA Y 6 Initially improved to independent sitting, standing, and holding head; then died from presumed respiratory failure (46)
2 3/M Hypotonic, areflexic, symmetric weakness of all limbs (MRC 2) ↓/↓ Y N Neck flop, prior sore throat, nasal regurgitation, inability to speak NA Y 5 Ventilator dependent
3 4/M Descending, asymmetric lower extremity paralysis (MRC 4) ↓/NL N Y Nasal voice, nasal regurgitation of food, progressive weakness, and inability to walk after throat symptoms improved NA Y 6 Died from respiratory failure (15)
4 3/M Symmetric, hypotonic, areflexic paralysis of the extremities (MRC 3) ↓/↓ Y Y Nasal voice and regurgitation with feeding ≈15–20 d after neck swelling NA N 3 No clinical improvement, remained hyporeflexic and hypotonic in limbs
5 4/M Symmetric, hypotonic, diffuse weakness, unconscious (unable to test) ↓/↓ Y Y Hyponasal speech, difficulty swallowing, nasal regurgitation 20 d after neck swelling NA Y 6 Died from cardiorespiratory failure while ventilator dependent (36)
6 6/M Symmetric, hypotonic weakness, lower extremity weakness (MRC 3) ↓/↓ Y Y Neck swelling and fever for 13 d, flaccid paralysis developed 30 d later with persistent voice change NL/NA Y 6 Died from cardiorespiratory failure while ventilator dependent (18)
7 6/F Symmetric, descending, hypotonic, lower extremity weakness (MRC 4) ↓/NL Y Y Nasal regurgitation and speech twang with enlarged glands and cervical adenopathy; weakness 13 d later NL/NL Y 6 Died from unclear reasons, presumed cardiorespiratory failure (37)
8 6/F Symmetric, ascending, hypotonic weakness (MRC 3) ↓/↓ Y Y Nasal twang, swallowing difficulty for 1 mo, then weakness involving legs and hands for <1 wk NA N 3 Strength improved by 1 point on MRC scale in upper and lower extremities
9 6/M No limb weakness (MRC 5) NL/NL Y Y Fever for 2 d, then sudden voice change with nasal regurgitation for 2–3 d, before pain and swelling of neck 2 weeks earlier NA N 0 Persistent palatal palsy
10 2/F Symmetric, descending, hypotonic weakness (MRC 4) ↓/↓ Y N Fever followed by nasal regurgitation and difficulty swallowing, progressive weakness in all limbs developed 2 d later NA N 4 Able to stand but requires support to walk
11 4/M Symmetric, hypotonic, lower worse than upper extremity weakness with prominent sensory symptoms (MRC 3 and 4) ↓/↓ N Y Throat and bulbar symptoms preceding limb weakness; throat swab negative NL/demyelinating Y 6 Serum given without noticeable improvement; died from cardiorespiratory arrest (13)
12 4/M Descending, symmetric, lower extremity predominant weakness (MRC 4) ↓/↓ N Y Nasal regurgitation preceding weakness NA/mixed axonal and demyelinating Y 6 Died from respiratory failure (21)
13 5/F Symmetric, diffuse, hypotonic weakness (MRC 4) ↓/↓ Y Y Nasal regurgitation NL/NA Y 6 Died from presumed cardiorespiratory failure (6)
14 14/M Complete flaccidity, areflexia, atonia; EMG showed no spontaneous motor activity or recruitment of motor unit potentials (MRC 0) ↓/↓ Y N History of positive throat swab result for Corynebacterium diphtheria NL/demyelinating Y 5 No spontaneous muscle activity; no response to IVIg
15 2/F Symmetric, 4-limb, lower extremity, predominant weakness (MRC 3 in lower extremities) NL/↓ N N Nasal regurgitation, speech change, and difficulty swallowing with fever, paralysis in <7 d NL/demyelinating N 4 Unable to walk

*CSF, cerebrospinal fluid; NCS, nerve conduction study; GBS, Guillain-Barré syndrome; NA, not available; N, no; Y, yes; MRC, Medical Research Council scale score; ↓, decreased or absent deep tendon reflexes; NL, normal; EMG, electromyogram; IVIg, intravenous immunoglobulin.

Main Article

1Current affiliation: Massachusetts General Hospital, Boston, Massachusetts, USA.

Page created: August 20, 2013
Page updated: August 20, 2013
Page reviewed: August 20, 2013
The conclusions, findings, and opinions expressed by authors contributing to this journal do not necessarily reflect the official position of the U.S. Department of Health and Human Services, the Public Health Service, the Centers for Disease Control and Prevention, or the authors' affiliated institutions. Use of trade names is for identification only and does not imply endorsement by any of the groups named above.