Open Access Research article

Epidemiology and clinical findings associated with enteroviral acute flaccid paralysis in Pakistan

Mohsan Saeed1, Sohail Z Zaidi2, Asif Naeem3*, Muhammad Masroor3, Salmaan Sharif4, Shahzad Shaukat4, Mehar Angez4 and Anis Khan3

Author Affiliations

1 Research Student, Department of Virology and Immunology, National Institute of Health, Islamabad, Pakistan

2 Head of Department of Virology and Immunology; Principal Investigator, WHO Regional Reference Laboratory for Polio Eradication Initiative, National Institute of Health, Islamabad, Pakistan

3 Virologist, WHO Regional Reference Laboratory for Polio Eradication Initiative, Department of Virology, National Institute of Health, Islamabad 45500, Pakistan

4 Molecular Biologist, WHO Regional Reference Laboratory for Polio Eradication Initiative, National Institute of Health, Islamabad, Pakistan

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BMC Infectious Diseases 2007, 7:6  doi:10.1186/1471-2334-7-6

Published: 15 February 2007

Abstract

Background

Enteroviruses are among the most common viruses infecting humans worldwide and they are associated with diverse clinical syndromes. Acute flaccid paralysis (AFP) is a clinical manifestation of enteroviral neuropathy, transverse myelitis, Guillian-Barre Syndrome, Traumatic neuritis and many other nervous system disorders. The objective of this study was to understand the role of Non-Polio Enteroviruses (NPEV) towards this crippling disorder.

Methods

Stool specimens of 1775 children, aged less than 15 years, suffering from acute flaccid paralysis were collected after informed consent within 14 days of onset of symptoms during January 2003 to September 2003. The specimens were inoculated on RD and L20B cells using conventional tube cell culture while micro-neutralization test was used to identify the non-polio enterovirus (NPEV) serotypes. Detailed clinical information and 60-days follow-up reports were analyzed for NPEV-associated AFP cases.

Results

NPEV were isolated from 474 samples. The male to female ratio was 1.4:1. The isolation of NPEV decreased significantly with the increase in age. Cases associated with fever at the onset of NPEV-associated AFP were found to be 62%. The paralysis was found asymmetrical in 67% cases, the progression of paralysis to peak within 4 days was found in 72% cases and residual paralysis after 60 days of paralysis onset was observed in 39% cases associated with NPEV. A clinical diagnosis of Guillian-Barre syndrome was made in 32% cases. On Microneutralization assay, echo-6 (13%) and coxsackievirus B (13%) were the most commonly isolated serotypes of NPEV along with E-7, E-13, E-11, E-4 and E-30. The isolates (n = 181) found untypable by the antiserum pools were confirmed as NPEV by PCR using Pan-Enterovirus primers.

Conclusion

The present study suggests that NPEV are a dominant cause of AFP and different serotypes of NPEV are randomly distributed in Pakistan. The untypable isolates need further characterization and analysis in order to determine their association with clinical presentation of a case.