1

MINISTRY OF HEALTH OF UKRAINE

DANYLO HALYTSKYI LVIV NATIONAL MEDICAL UNIVERSITY

PEDIATRIC INFECTIOUS DISEASES DEPARTMENT

GUIDELINES
FOR PRACTICAL CLASSES FOR 6th YEAR STUDENTS
SPECIALTY “GENERAL MEDICINE”
PROFILE COURSES OF CHOISE “INTERNAL MEDICINE”,

«DIFFERENTIAL DIAGNOSIS OF ENCEPHALITIS IN CHILDREN, CLASSIFICATION,

CLINICAL FEATURES, DIAGNOSIS, TREATMENT.
ENTEROVIRUS INFECTION, POLIO, MUMPS INFECTION.»

LVIV-2022

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Guidelines are made according to the Study program on Pediatric infectious diseases for students of
the second (Master Dergree) level of higher education in the field of knowledge 22 " Health Care "
specialty 222 "General Medicine"
The Guidelines have been compiled by H. Lytvyn (MD, PhD), Associate Professor, the Head of
Pediatric Infectious Diseases Department, O. Hladchenko (MD, PhD), Assistant professor of
Pediatric Infectious Diseases Department, Danylo Halytskyi Lviv National Medical University

Reviewed by: D. Dobriansky, Doctor of Medical Sciences, professor, Department of

Pediatrics №2 Danylo Halytskyi Lviv National Medical University
M. Shumylo Senior lecturer, of the Latin and Foreign Languages Department,
Danylo Halytskyi Lviv National Medical University

The editor-in-chief – E.Varyvoda, (MD, PhD) Associate Professor, the dean of

the Faculty of Foreign Students.
A. Nadraga Doctor of Medical Sciences, Professor, the dean of the medical faculty № 2, Danylo
Halytskyi Lviv National Medical University

Guidelines on the course of Pediatric Infectious Diseases

for students of the 5 t h year of General Medicine Faculty
“Approved” Protocol № 11 from 13.05.2022
Methodical Commission of Pediatric disciplines
Protocol № 3 from 13.06.2022

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Guidelines to lesson for students of the 6th year

DIFFERENTIAL DIAGNOSIS OF ENCEPHALITIS IN CHILDREN,
CLASSIFICATION, CLINICAL FEATURES, DIAGNOSIS, TREATMENT.
ENTEROVIRUS INFECTION, POLIO, MUMPS INFECTION.»

I.Aim: to teach students to recognize neuroinfections on the basis of patient

complaints, medical history, epidemiology, objective examination and paraclinical tests, to
assess the dynamics of the main clinical manifestations and laboratory parameters, to help
learn the principles of treatment of meningococcal infection in hospital, emergency measures
stage, to study measures to prevent this disease.
Professional motivation: infectious diseases with lesions of the nervous system occupy one of
the leading places in pediatric infectious diseases. The infectious process can affect all parts
of the central, peripheral and autonomic nervous system, meninges and blood vessels of the
brain. When the brain is affected, encephalitis develops, and the spinal cord develops
myelitis. A special group of neuroinfections are meningitis (lesions of the meninges and
spinal cord). The most favorable conditions for the development of the pathological process,
due to age-related anatomical and physiological features, are characteristic of children, in
particular at an early age. The rapid development of the disease, the severity of clinical
manifestations, late detection of the disease and inadequate treatment threaten death or
disability. Encephalitis is an inflammatory lesion of the brain as a result of a viral or bacterial
infection. The group of primary encephalitis caused by the direct effect of the virus on cells
and their damage includes enterovirus, herpes, adenoviral and some other encephalitis. The
group of secondary encephalitis includes all infectious-allergic encephalitis, the leading role
in the pathogenesis of which belongs to various antigen-antibody complexes or
autoantibodies that form an allergic reaction in the CNS (measles, chickenpox, rubella
encephalitis).
II. Primary aims of the study
A student should know:
1. etiology of poliomyelitis, enterovirus and mumps infections, encephalitis
(morphology, antigenic structure, classification, their pathogenic, virulent, invasive
and toxigenic properties)
2. epidemiology of the disease (source of infection, mechanism and ways of infection,
susceptibility, seasonality of the disease among young children and older)

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3. pathogenesis of the disease (entrance gate of infection, causes and pathogenesis of

encephalitis, polio, enterovirus and mumps infections, edema-swelling of the brain)
4. classification of clinical forms of various infections (severity, course of the disease)
5. clinical picture of polio, enterovirus and mumps infections in typical forms, especially
in children depending on age
6. complications of polio, enterovirus and mumps infections
7. methods of laboratory diagnostics (bacteriological, virological, serological, ELISA)
8. differential diagnosis of scarlet fever, yersiniosis, toxic influenza; serous meningitis
enterovirus, mumps, tuberculosis, leptospirosis, etc. etiology; purulent meningitis
pneumococcal, hemophilic, streptococcal, Purulent, Klebsiella, etc. etiology; mumps
infection should be differentiated from acute mumps, which occurs as a manifestation
of another disease (septicemia, cytomegalovirus infection, lymphogranulomatosis), on
the background of necrotic or gangrenous stomatitis; toxic mumps, salivary stone
disease, foreign body in the duct of the salivary gland, actinomycosis, salivary gland
tumors, pharyngeal diphtheria, lymphadenitis, phlegmon of the bottom of the mouth;
9. principles of treatment of a patient with polio, enterovirus and mumps infections,
encephalitis (indications for hospitalization, rules and means of etiotropic,
pathogenetic detoxification and dehydration, symptomatic therapy)
10. prevention measures (increase of sanitary and hygienic culture of the population, anti-
epidemic measures in the center: isolation of the source of infection, examination of
contacts)
student should be able:
1. follow the basic rules of work at the patient's bedside
2. collect a history of the disease
3. evaluate epidemiological data
4. examine the patient and, taking into account the patient's age, identify the main
symptoms of the disease (disorders of peripheral hemodynamics, hemorrhagic
exanthema, signs of damage to the central nervous system)
5. to reproduce the obtained data in the medical history and substantiate the previous
diagnosis
6. appoint a survey plan and evaluate the results of laboratory tests
7. substantiate the clinical diagnosis according to the classification of the disease
8. to carry out differential diagnosis of the disease

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9. prescribe treatment to the patient, taking into account the age, form and severity of the
disease, its complications, premorbid background:
10. in a hospital
11. at the prehospital stage
12. explain how to organize anti-epidemic measures in the center of infection

III. Educational aims of the study

- to form the deontological presentations, skills of conduct with the patients
- to develop deontological presentations, be able to carry out deontological approach to
the patient
- to develop the presentations of influence of ecological and socio-economic factors on
the health condition
- to develop sense of responsibility for the time of illness and loyalty of professional
actions
- to be able to set psychological contact with a patient and his family.

IV. Interdisciplinary integration

Table 1
Subjects To Know To Know How
Human Anatomy anatomy of the central
nervous system, especially in
young children
anatomy and topographic
anatomy of salivary, pancreatic,
genital, etc. glands, central
nervous system
Physiology To explain a variety of clinical signs
physiology of blood clotting,
and laboratory abnormalities
anatomical and physiological
features of hemodynamics,
microcirculation in young
children
physiology of glands of external

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and internal secretion, age

features of function of glands
which promote defeat of these
bodies,
Pathological To explain the main symptoms and
development mechanisms
Physiology manifestations appearance, causes of
inflammation and allergies relapses, failure of inadequate therapy
Pathological Anatomy pathomorphological changes in To explain the pathogenesis of
organs in encephalitis, complications and causes of death
enterovirus, mumps infections,
polio
Microbiology morphological, pathogenic, to collect material for bacteriological
virulent, invasive, toxigenic and serological research, to evaluate
properties of pathogens; the obtained results
methods of bacteriological and
serological testing)
Pharmacology The main antibacterial agents. To administer treatment of specific
Regimens of treatment. infection including antibacterial
Treatment of complicate. agents. To write the scheme of
Supportive care treatment of cases.
Pediatrics the method of objective To make an objective examination of
examination taking into account the patient, to evaluate the data
the age of the patient. clinical obtained. To differentiate from
manifestations of hemorrhagic meningococcal meningitis
vasculitis, thrombocytopenic
purpura
Neurology topographic diagnosis of Be able to differentiate from mumps
neurological lesions, age norms meningitis
of psychomotor development,
autonomic functions.
Neurosurgery methods of examination in case To differentiate from meningococcal
of suspicion of neurosurgical meningitis
pathology. clinical

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manifestations of volume
processes, brain abscess,
hydrocephalus
Gastroenterology method of examination in case of
suspicion of pancreatitis
Themes integration
Clinical manifestations To know peculiarities of To differentiate from meningococcal
of neuroinfections of manifestations, laboratory meningitis
other etiology, diagnostics, treatment
neurotoxicosis in acute
intestinal, respiratory
infections; infections
characterized by
exanthema

V. Planning of the lesson

Table 2
Time in %
The main stages
from total
of the lesson, The methods of control Methodical equipment
time of the
contents
lesson
10-20 %
1 Organizational
stage
2 Purposes of the Relevance of the 2-5 min
lesson Theme. Tutorial goals of
a lesson
3 Control of basic Control questions The list of control 15-25 min
knowledge and questions
skills
1.Etiology, Test-control (first grade) Tests of the first level
epidemiology,
classification of

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disease
2. Manifestations Methods of the second Questions
in connection grade: Individual
with questioning in oral and Clinical cases (tests of
pathogenesis written form. Standard task the second grade)
solution. Second grade test- Theory tasks for writing
control answers.
Second grade tests
3. Treatment Methods of the third grade: Third grade questions
1. Solution of complicated and tasks
tasks. Third grade tests
2.Third grade test-control
4. Prevention
70-80 %
1 Formation of Method of formation: Patients with studied 120-140 min
professional practical training disease and similar
skills diseases, patients’
histories, medical cases.
To master the Examination of the Laboratory data of the
skills of: patients, distinguishing of patients, antibacterial
a) Diagnosis the set of important signs drugs and drugs for
b) Laboratory and symptoms. supportive care
confirmation Composing of a plan of
c) Treatment laboratory confirmation.
Administration of the
treatment depending on the
form and severity of
disease.
Independent Examination of the patients Patients, patient’s
work with with Measles, Scarlet fever histories, medical cases.
patients and other infectious
diseases with similar
manifestations (differential

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diagnostics).
Differential Practical training Drawing schemes of
diagnostics pathogenesis and
clinical course of
disease; making up a
differential diagnostics
table and list of
prescriptions for
intensive care.
10 %
1 Teacher’s 10-15 min
control,
recommendation
s, the task for the
next lesson

Students’ self-study program.

1. Objectives for students' self-studies.
You should prepare for the practical class using the available textbook and lectures. Special
attention should be paid to the following:
№ Educational tasks Instructions for the task
STUDY
Etiology of polio, name, morphology, antigenic structure, classification of viruses, their
1 enterovirus and pathogenic, virulent, invasive and toxigenic properties
mumps infections,
encephalitis
Epidemiology source of infection, mechanism and ways of infection, susceptibility,
2 seasonality of the disease among young and older children
Pathogenesis entrance gate of infection, causes and pathogenesis of development,
3 encephalitis, meningoencephalitis, various clinical forms
Classification of typical, atypical forms, bacteriocarriers; severity, course of polio,
4 the disease enterovirus and mumps infections
Clinical symptoms main symptoms in typical and atypical course

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5 of typical forms polio, enterovirus and mumps infections

Laboratory virological, serological, ELISA, PCR, general clinical
6 methods
діагностики
Differential fill in the table of differential diagnosis of encephalitis depending on
7 diagnosis the pathogen and other CNS lesions;
More about this original textTo learn more about the translation, enter
the text of the original clinical forms of mumps, enterovirus infections,
polio
Treatment indications for hospitalization, rules and means of etiotropic,
8 pathogenetic detoxification and dehydration, symptomatic therapy
Prevention prevention of the spread of mumps, enterovirus infections, polio;
9 increase of sanitary and hygienic culture of the population, anti-
epidemic measures in the center: isolation of a source of an infection,
inspection of contact

The content of the team.

MUMPS
Mumps (AI) is an acute infectious disease characterized by general intoxication,
damage to the glandular organs (most often the salivary glands, especially the parotid,
pancreatic, genital organs), as well as the nervous system.
Etiology. The causative agent of mumps - Paramyxoviridae, RNA-containing virus.
Not very stable in the environment. Not sensitive to antibiotics and chemotherapeutics.
Representatives of this group are characterized by pronounced hemolytic activity, as well as
the ability to form syncytia in cell cultures and eosinophilic cytoplasmic inclusions.
Epidemiology. The source of infection is a sick person from the last day of the
incubation period to 9 days from the onset of the disease. The transmission path is airborne.
Susceptibility to mumps infection is determined by the contagiousness index, which is 0.3-
0.5. Maximum susceptibility at the age of 5 to 15 years. Children of the 1st year of life are
extremely ill. Outbreaks in children's institutions are more common in the cold season, due to
longer and closer contact indoors.
Clinic. The incubation period is from 11 to 21 days. The PI clinic is very diverse,
which is due to the different localization of the pathological process. The typical form of the
disease, mumps itself, usually begins acutely, with a rise in body temperature and swelling in
the parotid salivary glands (on one or both sides). The swelling fills the hole between the
branches of the mandible and the mammary process, can spread to the neck and face. The
skin over the affected gland is tense, shiny, but retains its normal color (not hyperemic). The
appearance of edema is accompanied by pain, which is exacerbated during chewing. After 1-
2 days, the second parotid gland swells. The face has a characteristic appearance, which is
associated with the name of the disease "mumps". The edema increases for 3-5 days, then
gradually decreases and disappears completely on day 8-10.

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Pancreatitis is typically characterized by severe girdle pain in the epigastric region.

There is nausea, repeated vomiting, and sometimes diarrhea.
Orchitis develops during puberty and in young men, usually after a previous, delayed
in time for 5-7 days, the defeat of the salivary glands. Manifestations of general intoxication
are clearly expressed: disturbances of the general condition, increase in body temperature to
39 ° C and above degrees, hemodynamic frustration. Pain in the testicle radiates to the groin
and lower back. The testicle swells, its size increases significantly, it becomes sharply
painful. The scrotum also swells. Occasionally there is bilateral orchitis. Manifestations of
general intoxication persist for 2-5 days, but the local inflammatory process persists for 10-14
days. In severe cases, testicular atrophy may occur.
Serous meningitis has an acute onset of the disease: headache, repeated vomiting,
fever up to 39 ° C. Meningeal symptoms are positive, sometimes questionable. Lumbar
puncture and examination of the cerebrospinal fluid reveal changes that indicate serous
inflammation of the meninges (increased protein content, lymphocytic pleocytosis from 200-
700 to 900-1000 and more in 1 μl). The course of mumps meningitis is usually benign.
Hospitalization is mandatory. Meningoencephalitis is rare. The clinical symptoms are clear,
due to diffuse cerebral edema. Other neurological manifestations include inflammation of the
auditory nerve with subsequent atrophy and hearing loss.
Complication. In the past, its atypical forms (orchitis, pancreatitis, serous meningitis)
were attributed to specific complications of PI. Now they are regarded as clinical
manifestations of the disease. Complications are rare and may be associated with the
activation of bacterial flora (pneumonia, otitis). Residual effects may also be observed:
deafness after auditory nerve neuritis, testicular atrophy after orchitis, diabetes mellitus after
pancreatitis.
Diagnosis and differential diagnosis. The diagnosis of a typical form of PI is usually
not difficult. However, sialoadenitis, purulent mumps, regional lymphadenitis should be
excluded. Atypical forms of PI (serous meningitis, encephalitis, pancreatitis, orchitis) are
manifested by appropriate clinical symptoms. Etiological interpretation is possible in the case
of time-consuming virological studies (isolation of the virus from blood, saliva, cerebrospinal
fluid). Serological diagnosis to determine the level of IgM to Paramyxoviridae is available in
commercial laboratories. Also, the presence of virus RNA fragments in body fluids (blood,
saliva, cerebrospinal fluid) can be detected by PCR.
In the hemogram of patients with PI leukopenia, relative lymphocytosis. With
pancreatitis, the level of diastase and amylase in the urine increases.
Treatment. The patient with EP must adhere to bed rest throughout the acute period of
the disease. Apply dry heat to the affected salivary glands. It is important to take care of the
oral cavity (rinsing with sodium bicarbonate 2% solution), frequent drinking. In the first days
of illness, food should be liquid or semi-liquid. According to the indications used
symptomatic drugs (analgesics, antipyretics). At an orchitis in the first days of an illness for
reduction of a pain syndrome apply cold on the struck site, impose a suspensory. It is also
advisable to conduct pre-detoxification therapy and the use of corticosteroids. In serous
meningitis, lumbar puncture has not only diagnostic but also therapeutic value (reduced
headache due to decreased cerebrospinal fluid pressure). Prevenous detoxification therapy,
corticosteroids and diuretics are also used in the first days of illness.
Prevention. Planned active prophylaxis of children with the CCP vaccine at the age
of 1 year and 6 years is carried out.
Activities in the cell. The patient with PI is isolated at home or hospitalized in the
presence of indications. Isolation period is not less than 9 days from the onset of the disease.
Quarantine is imposed on children under the age of 10 who have been in contact with a
patient with PI, provided that they have not had PI and have not been vaccinated against PI.

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The quarantine period is 21 days. If the exact time of contact is known, such children are
admitted to children's institutions in the first 10 days after contact (minimum SP) and isolated
from 11 to 21 days after contact. Final disinfection is not performed. After the sick room is
ventilated. Medical supervision is established for contacts in the cell. It is important to take
into account the erased and atypical forms of PI.

ENTEROVIRUS INFECTION are characterized by a variety of clinical

manifestations, from mild febrile conditions and simple carriers of the virus to severe
meningoencephalitis, myocarditis, myalgia, and others.
Enteroviruses are stable in the environment and can be found for a long time in
sewage, swimming pools, open water, milk, bread, vegetables, feces. Resistant to antibiotics.
Quickly inactivated by heating and boiling.
In addition to Coxsackie and ECHO viruses, there are 4 other types of enteroviruses
(68-71) that are well cultured in monkey kidney cell culture. Two of them (types 68, 69) are
the causative agents of respiratory and intestinal diseases, type 70 - hemorrhagic
conjunctivitis, and enteroviruses type 71 were isolated from patients with meningitis and
encephalitis.
Epidemiology. The source of infection are patients with clinically pronounced and
asymptomatic inapparent form (virus carriers). Viruses play an important role in the spread of
infection, especially in children. The patient is contagious in the last days of the incubation
period. In secretions from the nasopharynx, the virus is detected in the first 3 days after the
onset of the disease, with feces, the virus is excreted for a week or longer.
The mechanism of transmission of the pathogen - airborne and fecal-oral, through
infected water and food. Transplacental transmission of the virus is possible.
The susceptibility of children to enteroviruses is high. The most common patients are
children aged 3 to 10 years. Children under 3 months of age do not get sick due to the
presence of transplacental immunity. In older children and adults, enterovirus infection is
rare, due to the presence of immunity acquired as a result of asymptomatic infection.
The maximum incidence is registered in the spring and summer months. Periodic rises
with an interval of 3-4 years are possible.
Enterovirus infection is highly contagious, so when introduced into the children's
team, epidemic outbreaks easily occur with a large number of children. These outbreaks have
much in common with acute respiratory viral infections.
Clinical picture. Clinical manifestations of enterovirus infection are diverse due to
the tropism of Coxsackie and ECHO viruses to many human organs and tissues.
According to the leading clinical syndrome, the following forms of the disease are
distinguished: enterovirus fever, serous meningitis, encephalitis, herpetic sore throat,
epidemic myalgia, gastroenteritis, enterovirus exanthema, paralytic form, myocarditis,
encephalomyositis and other neoplasms.
The course of these forms can be isolated, but often together with the leading basic
syndrome clinical symptoms of other forms of a disease come to light. Such forms are called
combined. Despite the variety of clinical forms, it is possible to identify symptoms
characteristic of all typical forms of the disease.
The incubation period lasts from 2 to 10 days (usually 2-4 days). The disease begins
acutely, sometimes suddenly with a rise in body temperature to 39-40 ° C, there is repeated
vomiting, headache, dizziness, lethargy, sleep disturbances, decreased appetite. Hyperemia of
the mucous membranes of the tonsils, granularity of the soft palate, arches and posterior
pharyngeal wall are determined. The tongue is covered. All forms are characterized by
redness of the skin of the upper half of the torso (especially the face and neck), injection of

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scleral vessels. A polymorphic maculopapular rash may appear on the skin. Cervical lymph
nodes are slightly enlarged, not painful. There is a tendency to constipation.
In the peripheral blood, the number of leukocytes is normal or slightly elevated. Often
detected moderate neutrophilia, which changes in the late periods of lymphocytosis and
eosinophilia. ESR is usually within normal limits or slightly elevated.
The course of the disease, the results and duration of the febrile period depend on the
severity and form of enterovirus infection
Serous meningitis and encephalitis are one of the typical forms of enterovirus
infection. It begins acutely, with a rise in body temperature to 39-40 ° C. Severe headache,
dizziness, repeated vomiting, agitation, restlessness, sometimes abdominal pain, delirium and
convulsions appear. Characteristic appearance of the patient: the face is hyperemic, slightly
pasty, the sclera is injected. The mucous membranes of the oropharynx are hyperemic, there
is granularity on the soft palate and the posterior wall of the pharynx. Meningeal symptoms
appear from the first days: occipital muscle rigidity, Kernig and Brudzinski symptoms.
Abdominal reflexes are reduced. Often meningeal syndrome is weakly or incompletely
expressed, there are no separate symptoms (dissociation of a meningeal symptom complex, ie
there can be only Kernig's symptom or insignificant rigidity of occipital muscles). Meningeal
symptoms are manifested at the height of the temperature response. In some cases, clinical
forms may be observed without typical meningeal symptoms, but with pronounced changes
in the cerebrospinal fluid, in other cases, with pronounced clinical manifestations of
meningitis, there are no changes in the cerebrospinal fluid (hypertension syndrome).
At a spinal puncture cerebrospinal fluid is transparent, follows under pressure. Cytosis
up to 200-300 cells in 1 mm. At the beginning of the disease, cytosis is usually mixed
(neutrophil-lymphocyte), and then exclusively lymphocytic. The content of protein, sugar and
chlorides is usually not increased, the Panda reaction is weakly positive or negative.
Coxsackie or ECHO viruses can be isolated from the cerebrospinal fluid.
Clinical manifestations of meningitis last 3-5 days, and normalization of cerebrospinal
fluid occurs in the 3-4th week from the onset of the disease. Possible recurrence of serous
meningitis. After the disease for 2-3 months
Paralytic form of enterovirus infection is the rarest of all forms of enterovirus
infection. Young children get sick more often. The disease begins acutely, with fever, mild
catarrhal phenomena and the appearance of flaccid paralysis. Often paralysis occurs at
normal body temperature and complete well-being. At the same time, the child's gait is
disturbed, there is weakness in the legs, less often in the hands. Muscle tone is reduced,
tendon reflexes on the affected side are moderately reduced. Cerebrospinal fluid is often
unchanged. In some cases, there is an isolated lesion of the facial nerve of the peripheral type,
possible lesions of other cranial nerves. The course of the paralytic form of enterovirus
infection is mild and leaves almost no persistent paralysis, in contrast to polio.
Diagnosis. It is very difficult to diagnose enterovirus infection in sporadic diseases.
Only in cases where the disease has a characteristic symptom complex for this infection
(herpetic sore throat, epidemic myalgia, encephalomyocarditis in newborns), we can assume
the enteroviral nature of the disease.
During epidemic outbreaks in the team in the presence of patients with typical clinical
forms can be detected and erased forms of enterovirus infection.
Laboratory methods:
Virological method. The material for the study are flushing of the oropharynx, blood,
cerebrospinal fluid, feces.
Serological methods. Examine blood sera in RN and RZK. An increase in the titer of
specific antibodies more than 4 times in the dynamics of the disease is a reason to diagnose
the enteroviral nature of the disease. Methods of direct and indirect immunofluorescence,

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enzyme-linked immunosorbent assay, which allow to detect the virus antigen in the test
material have been developed. Polymerase chain reaction (PCR) of cerebrospinal fluid,
blood.
Differential diagnosis. Enterovirus infection has to be differentiated from acute
respiratory viral diseases. typhoid-paratyphoid infection, serous meningitis of other viral and
tuberculous etiology, acute appendicitis, cholecystitis, pancreatitis, rubella, drug-induced
rash, yersiniosis, stomatitis of bacterial etiology and herpetic mycocarditis, polyposis, In any
case, all available laboratory methods should be used to rule out polio, as well as to study the
epidemic situation.

POLIOMYELITIS
acute infectious disease caused by one of the three types of poliovirus and
characterized by a wide range of clinical manifestations - from abortive to paralytic forms.
Etiology. Family - Picornaviridae, genus - Enterovirus, species - human enteroviruses
of group C. Poliovirus types 1 (Brunhilda), 2 (Lansing) and 3 (Leon). The virus has an
icosahedral shape, built of protein subunits. Quasi-equivalent packaging is achieved by 3
different polypeptides, 60 copies of each of the proteins VP1, VP2 and VP3. The genome
consists of a single unfragmented RNA molecule and contains about 7,500 nucleotides.
Epidemiology
The source of infection - patients, virus carriers. Poliovirus is isolated by patients and
patients with polio for 2 to 7 weeks, sometimes up to 4 months.
Way of transfer - air-drop, alimentary, contact-household, water;
Susceptibility - high, especially in children under 3 years.
Immunity is post-infectious: very intense and lifelong. Recurrent cases of polio
caused by another type of virus are possible. Immunity is associated with the presence of
virus-neutralizing antibodies and cellular factors that produce secretory immunoglobulins A.
Humoral immunity is type-specific.
Classification:
I. Without CNS damage: inapparent, abortive or visceral.
ІІ. With CNS damage.
1. Non-paralytic - meningeal (serous meningitis)
2. Paralytic forms
a) spinal (motor neurons of the anterior horns of the cervical, thoracic, lumbar spinal
cord);
b) bulbar (motor nuclei of cranial nerves located in the medulla oblongata: IX, X, XI,
XII pairs);
c) pontine (motor nuclei of V, VI, VII pairs of cranial nerves);
d) mixed (pontospinal, bulbospinal, bulbopontospinal).
The meningeal form of polio is a type of serous meningitis with one- or two-wave
course. At a two-wave current the first wave proceeds without defeat of serous covers,
repeats symptomatology of an abortive form of poliomyelitis. Characteristic severity of
autonomic manifestations in the form of sweating, especially the head, lability of the pulse,
blood pressure, hypotension, tachycardia, pink dermographism, horizontal nystagmus.
The paralytic form of polio has periods:
1) incubation;
2) preparalytic;
3) paralytic (characterized by the development of distal flaccid paralysis with
preserved sensitivity);
4) restorative;
5) residual.

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Prevention.
Specific prevention of enterovirus infection has not been developed. For prophylactic
purposes, human leukocyte interferon can be used in the center of infection (instilled into the
nasal passages 5 drops 3-4 times a day for 10-15 days).
Early diagnosis and timely isolation of patients until the disappearance of clinical
symptoms is of great anti-epidemic importance.
Vaccination against polio is carried out with live (OPV) or inactivated (IPV) vaccine:
1 dose - at the age of 2 months (IPV), 2 dose - at 4 months (IPV), 3 dose - at 6 months
(OPV), 4 dose - in 18 months (OPV), 5 dose - at 6 years (OPV), 6 dose - at 14 years (OPV).
The primary vaccine complex consists of 4 doses of polio vaccine, the first two of which
must be an inactivated vaccine.
Infectious diseases of the nervous system in children can be accompanied by such
urgent conditions as infectious-toxic shock and swelling of the brain.
Diagnosis.
Isolation of poliovirus from feces, saliva, nasopharyngeal mucus, blood during the
first week of the disease (on tissue cultures). To identify the virus, you need to examine the
stool and mucus from the nose of the throat. In the mouth of the throat, it is detected within 5
days after the onset of the disease, with feces excreted intermittently, so you need to take 2
samples with an interval of 24-48 hours.
Increase in the diagnostic titer of antibodies during the disease; use RZK and
precipitation (neutralization) reaction with a specific antigen in paired sera taken at intervals
of 3-4 weeks. An increase in antibody titer (BP) of 4 times or more in paired sera taken at
intervals of 10–14 days is of diagnostic value.
Using molecular biological methods, the isolated virus is differentiated from vaccine
strains or typing using type-specific neutralizing sera.
At a spinal puncture the cerebrospinal fluid is usually transparent, colorless, pressure
can be increased, moderate lymphocytic cytosis (30–40 x 109 / l, sometimes with
predominance of neutrophils, but then mainly lymphocytic) is found. The content of protein
and glucose - within the physiological norm or slightly elevated (signs of serous meningitis).
Electromyography does not detect the pathogen, but this method can be used to
determine which of the muscles are insufficiently innervated due to damage to motor
neurons.
Treatment:
In the acute period
1. Mandatory hospitalization
2. Physical and mental peace
3. Analgesics (analgin 50% 0.1 ml / year of life, bromides)
4. Thermal procedures (hot wraps, ozokerite, paraffin applications)
5. Dehydrating agents (Lasix 1-3 mg / kg, mannitol, mannitol 1-1.5 g / kg)
6. Corticosteroids (in severe cases) 1-3 mg / kg of prednisolone
7. Human immunoglobulin 0.5 ml / kg 2-3 days

In the early recovery period

1. Proserine 0.001 g / year of life, galantamine, dibazole 0.001-0.005 g per day for 20-
30 days
2. Exercise therapy, UHF, ozokeritotherapy, diathermy, massage
3. Vitamins (B6, B12), ATP
4. Anabolic steroids (2-3 courses per year)
In the residual period
1. orthopedic correction

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Prevention. Polio is a controlled infection, so the main means of combating it is

vaccination, which in Ukraine is included in the Calendar of preventive vaccinations,
registered live polio vaccines (OPV) and inactivated (IPV).
Prevention. Polio is a controlled infection, so the main means of combating it is
vaccination, which in Ukraine is included in the Calendar of preventive vaccinations,
registered live polio vaccines (OPV) and inactivated (IPV).
Control tests for the topic

1. What acid does the mumps virus contain?

a. RNA
b. hydrochloric acid
c. DNA
d. stearic

2. What is the road of transmission with mumps?

a. air-drop
b. fecal-oral
c. transmissible
d.contact and household

3. Entrance gates for mumps infection are, except:

a. oral mucosa
b. conjunctiva of the eyes
c. pharyngeal mucosa
d. nasal mucosa

4. Which of the factors determines the severity of clinical manifestations of mumps

infection?
a. endotoxin
b. exotoxin
c. virus
d. erythrogenic toxin

5. Typical clinical forms of mumps infection, except:

a. nervous
b. glandular
c. combined
d.intestinal

6. The most common localization of mumps is:

a. lesions of the parotid salivary glands
b. lesions of the submandibular salivary glands
c. sublingual salivary gland lesions
d. lesions of the pancreas

7. Lesions of the gonads in mumps infection are most often observed in:
a. young children
b. newborns
c. adolescents and adults
d. elderly people

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8. Symptoms of mumps are, except:

a. soreness when chewing on the affected side
b. smoothing the pit between the lower jaw and the papillary sprout
c. swelling around the ear
d. bright redness of the skin over the swelling around the ear

9. Clinical manifestations of pancreatitis in mumps infection are, except:

a. sharp convulsive abdominal pain
b. increase in body temperature
c. nausea, vomiting, constipation or diarrhea
d. spotted-papular exanthema

10. For which age group is the most characteristic lesion of the central nervous system.
a. young children
b. older children
c. newborns
d. elderly people

11. What is the active immunization against mumps?

a. live attenuated vaccine
b. killed vaccine
c. immunoglobulin
d. Anatoxin

12. For the diagnosis of mumps infection use the following methods, except:
a. virological examination
b. serological examination
c. bacteriological examination
d. objective review

13. Enteroviruses include viruses, except:

a. polioviruses
b. Coxsackie viruses
c. ENSO viruses
d. arboviruses
e. unclassified enteroviruses

14. How many types of antigenic properties are divided into polio viruses?
a. two
b. three
c. four
d. Eight
e. twenty

15. How many groups are Coxsackie viruses divided into?

a. two
b. three
c. four
d. Eight

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e. twenty

16. The mechanism of infection in polio, EXCEPT:

a. air-drop
b. fecal-oral
c. transmissible
d.contact and household
e. alimentary

17. Where are the maximum pathomorphological changes in the paralytic form of polio?

a. anterior horns of the spinal cord

b. posterior horns of the spinal cord
c. cortex
d. peripheral nerve trunks
e. meningeal membranes

18. For clinical manifestations of paralytic poliomyelitis are characterized by periods,

EXCEPT:
a. exanthema
b. paralytic
с. recovery period
d. period of residual phenomena
e. preparalytic

19. Which of the paralytic forms of polio is the most typical?

a. encephalitic
b. bulbar
c. pontine
d. spinal
e. meningeal

20. Non-paralytic forms of poliomyelitis are, exept:

a. inapparent
b. abortive
c. meningeal
d. spinal
e. bulbar

21. To diagnose polio, examination methods are used, EXCEPT:

a. virological
b. serological
c. clinical
d. bacteriological
e. immunological

22. What are the features of paralysis in polio?

a. flaccid, asymmetrical, mosaic, with preserved sensitivity
b. spastic, asymmetric, mosaic, with preserved sensitivity
c. flaccid, asymmetrical, mosaic, with lost sensitivity

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d. spastic, asymmetric, mosaic, with lost sensitivity

1-а 6-а 11 - c 16 - а 22 - а
2-а 7-d 12 - а 17 - а
3-b 8-d 13 - d 18 - а
4-c 9-d 14 - b 19 - а
5-d 10 - b 15 - e 21 - b
Recommended cases
1. A 5-year-old girl became acutely ill with a sore throat, fever up to 38.5 ° C. Objectively:
hyperemia of the mucous membrane of the oropharynx, herpetic rash on the anterior palatal
arches. The patient's sister is in hospital for serous meningitis.
Which of the following laboratory diagnostic methods is the most informative for
determining the presumptive diagnosis?

2. A 4-month-old child became acutely ill: his body temperature rose to 38oC, he developed
a runny nose, cough, and restlessness. She was hospitalized with a diagnosis of "ARVI" in
the children's diagnostic department. A lumbar puncture was performed due to the detection
of weakly positive meningeal symptoms. The cerebrospinal fluid is aseptic (serous). On the
7th day of the disease and against the background of the disappearance of these symptoms,
the child developed peripheral paralysis of the facial nerve.
Your diagnosis? Make a plan for laboratory diagnosis and treatment.

3. Patient, 3 years old, fell ill in August: body temperature 37.6oC, sparse stools 3-4 times a
day for 4 days, lethargy, stopped getting up. On the 5th day, they noticed restrictions on
movement in the right leg, and the next day he stopped moving it. There are no sensitivity
disorders.
Your previous diagnosis? Which method of laboratory diagnosis is the most informative for
determining the presumed diagnosis?

4. The child, 13 years old, became acutely ill: body temperature 39 oC, sore throat, runny
nose. From the second day of the disease - pain along the spine and leg muscles. The
condition is severe: pale, adynamic, pronounced general hyperesthesia. Palpation of the leg
muscles is sharply painful, the pain when pressing on the spinal processes. Hyperhidrosis of
the skin of the feet. Positive symptoms of Neri, Lasega. On day 5, there was weakness and
restriction of movement in the muscles of the left thigh and peripheral paresis of the right
facial nerve. No knee reflex on the right. There are no sensitivity disorders.
Your previous diagnosis?

5. A 5-year-old girl became acutely ill: sore throat, fever up to 38.6oC. Objectively:
hyperemia of the mucous membrane of the oropharynx, herpetic rash on the anterior palatal
arches. The patient's sister is being treated for serous meningitis.
What preliminary diagnosis is most likely? Assign laboratory diagnostics. Make a treatment
plan.

6. In September, 6 children in the kindergarten group showed signs of bilateral hemorrhagic

conjunctivitis, in three of them the disease progressed with an ephemeral spotted rash on the
face and torso.

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What do you think is the etiology of the outbreak? Which laboratory method of diagnosis is
the most informative in this case? What anti-epidemic safety measures should be applied in
this case?

7. A 2.5-year-old child was referred to an infectious disease hospital for motor disorders. At
hospitalization the child is sharply pale, tearful, does not sit. Weak paresis of the lower
extremities, more pronounced on the right, paresis of the deltoid muscle on the left.
Sensitivity is preserved.
What preliminary diagnosis is most likely? Schedule a laboratory diagnosis and make a
treatment plan.

References:
1. Kramarev B. B. Pediatric infectious diseases / B. B. Kramarev, O. B. Nadraga. – Kyiv,
2015. – 238 с.
2. Long S. S. Principles and Practice of Pediatric Infectious Diseases / S. S. Long, K. L.
Pickering, G. C. Prober. – Churhill Livingstone, 2017. – 1618 с. – (Fifth edition).
3. Textbook of Pediatric Infectious Diseases / [J. Cherry, G. G. Demmler-Harrison, S. L.
Kaplan та ін.]., 2018. – 1618 с. – (Eight edition).
4. Nelson Textbook Of Pediatrics - Volume 1 & 2 (International Edition) Edition:
eighteenth by Robert M Kliegman Richard E Behrman Hal B Jenson Bonita F Stanton. –
21th Edition. – 2018. – 3250 р.

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