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943) And, of course, acute poliomyelitis is still a frequent illness in regions of the world where vaccines are not available For these reasons and also because it stands as a prototype of a neurotropic viral infection, the main features of the disease should be known to neurologists Etiology and Epidemiology The disease is caused by a small RNA virus that is a member of the enterovirus group of the picornavirus family Three antigenically distinct types have been de ned, and infection with one does not protect against the others The disease has a worldwide distribution; the peak incidence of infection in the northern hemisphere was in the months of July through September Poliomyelitis is a highly communicable disease The main reservoir of infection is the human intestinal tract (humans are the only known natural hosts), and the main route of infection is fecaloral, ie, hand to mouth, as with other enteric pathogens The virus multiplies in the pharynx and intestinal tract During the incubation period, which is from 1 to 3 weeks, the virus can be recovered from both of these sites In only a small fraction of infected patients is the nervous system invaded Between 95 and 99 percent of infected patients are asymptomatic or experience only a nonspeci c illness It is the latter type of patient the carrier with inapparent infection who is most important in the spread of the virus from one person to another Clinical Manifestations The large majority of infections are inapparent, or there may be only mild systemic symptoms with pharyngitis or gastroenteritis (so-called minor illness or abortive poliomyelitis) The mild symptoms of poliomyelitis correspond to the period of viremia and dissemination of the virus; they give rise in most cases to an effective immune response a feature that accounts for the failure to cause meningitis or poliomyelitis In the relatively small proportion of patients in whom the nervous system is invaded, the illness still has a wide range of severity, from a mild attack of aseptic meningitis (nonparalytic or preparalytic poliomyelitis) to the most severe forms of paralytic poliomyelitis Nonparalytic or Preparalytic Poliomyelitis The prodromal symptoms consist of listlessness, generalized, nonthrobbing headache, fever of 38 to 40 C (1004 to 104 F), stiffness and aching in the muscles, sore throat in the absence of upper respiratory infection, anorexia, nausea, and vomiting The symptoms may subside to a varying extent, to be followed after 3 to 4 days by recrudescence of headache and fever and by symptoms of nervous system involvement; more often the second phase of the illness blends with the rst Tenderness and pain in the muscles, tightness of the hamstrings (spasm), and pain in the neck and back become increasingly prominent Other early manifestations of nervous system involvement include irritability, restlessness, and emotional instability; these are frequently a prelude to paralysis Added to these symptoms are stiffness of the neck on forward exion and the characteristic CSF ndings of aseptic meningitis These symptoms may constitute the entire illness; alternatively, the preparalytic symptoms may be followed by paralytic ones Paralytic Poliomyelitis The weakness becomes manifest while the fever is at its height, or, just as frequently, as the temperature falls and the general clinical picture seems to be improving Muscle weakness may develop rapidly, attaining its maximum severity in 48 h or even less; or it may develop more slowly or in stuttering fashion, over a week, rarely even longer As a general rule, there is no progression of weakness after the temperature has been nor-.

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