Announcement

**alert** · January 26, 2011, 03:55 AM

Re: Haiti - PAHO/WHO investigating at least seven cases of paralysis in cholera patients

More details from ProMED. It is far from clear what is going on here, but polio and GBS both seem unlikely.

http://www.promedmail.org/pls/apex/f..._ID:1000,86826

Archive Number 20110125.0307
Published Date 25-JAN-2011
Subject PRO/EDR> Acute flaccid paralysis - Haiti (02): ?post cholera, RFI

ACUTE FLACCID PARALYSIS - HAITI (02): ? POST CHOLERA, REQUEST FOR INFORMATION
************************************************** ***************************
A ProMED-mail post
<http: www.promedmail.org="">
ProMED-mail is a program of the
International Society for Infectious Diseases
<http: www.isid.org="">

Date: 22 Jan 2011

[This is apparently an interview conducted and edited by Jim Wil son V M.D.] s.s.
<jim.wilson@praecipiointernational.org>

Summary of the interview with Dr Mozart Cherubin (Hospital Director)
and Dr. Vilton, Beraca Hospital, Commune La Pointe, Port-de-Paix.
Interview held on 12 Jan 2011

- Cases presented to Baraca Hospital, Commune de La Pointe, Port-de-Paix

- Cases were 1st admitted to the CTC [cholera treatment center] for
cholera treatment.

- Cases 1-4 were in hypovolemic shock when admitted [which makes mistaking polio for cholera extremely unlikely - alert].

- During this interview they corrected previous version about
hospital discharge: only case 3 was discharged.

- For those who died, death certificates are not available [for us to
see] (They were not admitted to the CTC so the death registration is
in the main hospital and not the cholera [treatment center - CTC])

- All cases presented similar symptoms of paralysis within 72 hours
of recovery.

- Symptoms consisted of: ascending bilateral flaccid paralysis
leading to difficulty in speech, loss of consciousness and then
respiratory distress. Paralysis was highlighted in cases 2, 3 and 4,
while hypotony was the main symptom for cases 6 and 7.

- All cases were treated with ORS [oral rehydration salts], Ringers
lactate, dextrose 5 percent or saline solutions, and doxycycline
(oral) in adults; erythromycin (oral) in children. The severe cases
were also treated with ceftriaxone IV [intravenous] (this is sure for
case 3, but during the interview they said that 5 severe cases were
given ceftriaxone -- they could be cases 1,2,4, and 5). Case 5 was
also treated with dexamethasone. At some point during the interview
they mentioned the use of metroclopramide for cases with severe
vomiting, but denied its administration to these cases. No clinical
history available to check treatments. All this information was
provided orally.

- Medicines and RL, etc are provided by different organizations.
(MSPP/ PROMESS, MTI, MSH/USAID).

- All cases died except cases 4, 6 and 7.

- Both doctors said that they have never seen similar cases. For the
last 10 years, only 2 diagnoses of GBS [Guillain-Barre Syndrome] have
been made in this hospital (they were a 1 [year old] and a 4 [year old])

- Among the cases reported, cases 2, 3 and 4 cluster in time and seem
to fit the same clinical presentation. Case 1 may also belong to this
cluster but the reporting doctor was not sure. As for case 5,
reporting doctor was dubious. Cases 6 and 7 may be subject to recall
bias. They have heard about the 12 [year old] female transferred to
Charlotte (USA) but didn't know where she came from.

- They were questioned regarding particular diets or food that may
have been given to these cases. They discarded this possibility. They
mentioned fish (tetrodotoxin?) is not usually given to sick people.
There are no similar cases among family members. They were reluctant
to talk about traditional practices.

Case 1: Female. 5-6 years old. Died. Admitted at the beginning of
November [2010] to Beraca Hospital's CTC with cholera. Severe clinical
presentation. Recovered and was about to be discharged when she
started with asthenia, hypotonic in both legs which rapidly evolved
into an ascending, generalized flaccid paralysis, respiratory distress
and died within 24 hours. Address unknown: somewhere in Port de Paix
or Sant Louis du Nord. This case was notified retrospectively after
death.

Case 2: Male. 17 years old. Died. Admitted at the beginning of
December [2010] to Beraca Hospital's CTC with cholera. Also severe
clinical presentation. Recovered in 3-4 days, when he started with
hypotonic paralysis in both legs, which evolved in 24 hours to
paralysis of both arms, weak voice, severe dysarthria. Conscious until
death 48 hours after clinical presentation of paralysis. Date of
death: [13 Dec 2010]. Diagnosed as GBS. Address unknown: somewhere in
Lavaud. He was treated with IV [intravenous] potassium after paralysis
onset.

Case 3: Female. 36 years old. Died. She was a nurse/auxiliare working
at Beraca's CTC. She was admitted to the same CTC with cholera,
mid-December [2010]. Also severe clinical presentation. After
recovery, she was discharged (a Monday), went home and on Wednesday
afternoon couldn't move her legs. She was admitted to hospital on
Wednesday night (22 Dec 2010) with paralysis. She rapidly developed
ascending paralysis with difficult speech, respiratory distress, and
coma and died on Sun 26 Dec 2010. She had fever at the end and was
diagnosed of respiratory infection and treated with ceftriaxone IV. No
similar cases amongst family members. She has 3 children aged 15, 13,
12 [years old]. Stool samples from these children have been requested.
Address: La Pointe (nearby Beraca hospital).

Case 4: Male. 34 years old. Alive. Initially admitted for cholera at
Abricot CTC, 18 hours later [he] was admitted to Beraca CTC with
diarrhea and vomiting (on [27 Dec 2010]). Severe clinical presentation
with hypovolemic shock. Day before date of discharge, started with
pain in his legs (mainly in the left leg). The following day he
couldn't stand up and was completely paralyzed within hours.
Transferred to PaP on 02 Jan 2011(alive). Diagnosed as GBS. Address:
St Louis du Nord.

Case 5: Male. 85 years old. Died. Referred to Beraca hospital from
other health facility for cholera complications and flaccid paralysis.
Has been reported retrospectively after death (and during our
investigation).

Case 6: Male. 3 years old. Alive. Reported retrospectively during
interview. Admitted to Beraca hospital sometime during the 2nd-3rd
week of November [2010] with cholera. Presented generalized hypotony,
swollen abdomen (not sure at what moment, during or after the cholera
episode). Clinical symptoms lasted for 3-4 days. Was treated with
potassium and B complex with full recovery. Address: Port-de-Paix.

Case 7: Male. 6 years old. [Alive] Admitted last week of November/
beginning of December [2010] to Beraca Hospital's with hypothonia. Had
been treated for cholera in another CTC (Abricot?, Gaspin?) Recovered
in 72 hours. Address unknown.

Note: There is another case reported by informal sources edit
regarding a 12-year-old female transferred from PaP to Charlotte (USA)
with a similar clinical description (generalized flaccid paralysis,
respiratory distress). Her department of origin is unknown.

ACTIONS
A sampling kit with laboratory forms was left at the hospital.
- Doctors were requested to take samples from the 3 children of case 3.
- They were also requested to notify immediately to DSNO and
PAHO-alerts any incoming case of paralysis and to take samples.

--
Communicated by:
James M. Wil son V, MD

<jim.wilson@praecipiointernational.org>

[ProMED-mail originally decided to hold off posting this summary until
more information was available to permit a better definition of what
might be going on. This moderator just found a report on a newswire
stating that ProMED-mail had reported on an outbreak of polio in
Haiti. While the possibility of polio was discussed in the original
post and is still in the differential diagnosis, upon review of this
latest information, this moderator feels that more information was and
is still necessary before coming to any firm conclusions. Hence the
perceived need to post this information now and request further
clarification on what is going on.

As an aside, in prior presentations of clusters of acute flaccid
paralysis consistent with polio that ProMED-mail has covered, a
definitive diagnosis of polio was made within a few days following the
initial alert of the paralytic cases.

From the above descriptions of the clinical presentations, it appears
as though all patients thus far identified to have had an acute onset
of flaccid paralysis, had onset of their symptoms within a few days of
presenting to cholera treatment units for presumptive cholera [or
could it be a non-cholera gastroenteritis due to another organism such
as campylobacter or a viral agent such as an enterovirus?].
Unfortunately the above case descriptions do not provide information
on laboratory studies.

Reading through the descriptions of the cases one does wonder what
might be triggering a Guillain-Barre syndrome (GBS)-like illness. But,
that being said, a review of the literature did not reveal much
identifying a strong association of GBS with cholera. But, GBS post
antigen exposure (respiratory and gastrointestinal infections,
vaccinations) usually occurs with an interval of 2-3 weeks following
the original antigenic exposure (see Schonberger LB, Bregman DJ,
Sullivan-Bolyai JZ, Keenlyside RA, Ziegler DW, Retailliau HF, Eddins
DL, Bryan JA. Guillain-Barre syndrome following vaccination in the
National Influenza Immunization Program, United States, 1976--1977. Am
J Epidemiol. 1979 Aug;110(2):105-23.).

Another "hallmark" of GBS is a strong sensory component, and the above
descriptions do no mention a sensory component as part of the clinical
picture.

Hence, at present, given the limited information available, drawing a
conclusion as to the etiology of the above described paralytic cases
at this point in time is premature and risky. None of the diagnoses
speculated have been either ruled in or ruled out as yet.

This moderator would like to repeat the request for more information
from knowledgeable sources in the Region.

For the interactive HealthMap/ProMED map of Haiti, see
<http: healthmap.org="" r="" 00yn="">. - Mod.MPP]</http:></jim.wilson@praecipiointernational.org></jim.wilson@praecipiointernational.org></http:></http:>

**alert** · January 26, 2011, 03:39 PM

Re: Haiti - PAHO/WHO investigating at least three cases of paralysis in cholera patients

Presumably, the four cases are the three in Beraca CTC and the one in Charlotte, although the fourth case could be the 85-year-old man. If it is the Charlotte case, then the one surviving case in Haiti would have died.

original source:

http://new.paho.org/hq/index.php?opt...46&Itemid=1926

PAHO/WHO Investigating Paralysis Cases in Port-de-Paix, Haiti
Featured In: Pan American Health Organization
By Pan American Health Organization
Wednesday, January 26, 2011

Washington, DC, January 26, 2011 (PAHO/WHO) - Officials from the Pan American Health Organization/World Health Organization (PAHO/WHO), along with colleagues from Haiti's Ministry of Health and the U.S. Centers for Disease Control and Prevention (CDC), are looking into four cases of paralysis in recovering cholera patients in Port-de-Paix, Haiti, and are likely to rule out polio as a cause, pending laboratory results.

Experts including toxicologists are investigating possible contamination at a hospital or at home from medication, food, or another source as the cause of death in these cases. PAHO and CDC officials are conducting field studies and will report their findings as soon as laboratory results are available.

Polio was one of the first possibilities looked into because of the public health implications. However, the clinical characteristics and epidemiology of these cases make poliomyelitis a remote possibility; in simple terms, polio does not produce a high mortality rate. Although considered highly unlikely, polio has not been completely ruled out, pending laboratory results of samples.

PAHO/WHO has suggested that health officials remain vigilant for further cases and has supported local health authorities in the investigation with technical staff including epidemiologists, a clinician and an immunization nurse to continue the investigations. A nurse who works with PAHO/WHO's immunization program returned from visiting the affected communities Monday with samples from some of the families. A PAHO/WHO clinician and a PAHO/WHO immunization advisor are participating in the investigation.

PAHO/WHO field epidemiologists and local health authorities from the Department of Nord-Ouest first reported a cluster of acute neurological syndromes in that department January 10, 2011. As of January 24, 2011, four cases with acute neurological syndrome, including three deaths, were reported, with dates of onset from November to December 2010 in the La Pointe area, Commune Port-de-Paix, and the neighboring commune of Saint Louis du Nord. All of the cases were seen at the same cholera treatment center and returned 2-4 days later with neurological symptoms, at which point they were hospitalized.

Working with the Director of the Department of Nord-Ouest and local officials, interviews with medical staff and relatives showed that the patients were admitted to the hospital between early November and the end of December. These patients, hospitalized for severe cholera, presented an ascending bilateral flaccid paralysis of acute onset 24 to 72 hours after the end of the cholera treatment. No additional cases were detected after the initial field investigation in the Nord-Ouest Department. Samples of blood, feces, and CSF were taken from one patient, and laboratory results are still pending. PAHO/WHO field epidemiologists and local health authorities notified the central Alerts and Response Unit of these cases January 10.

Of the suspected cases, only four had symptoms and signs compatible with paralysis. Three have died, and one is hospitalized in Port-au-Prince. He is recovering slowly. As a prudent measure, polio vaccine has been added to an upcoming vaccination campaign against diphtheria and measles in the Nord-Ouest Department.

Polio was eradicated from the Americas in 1994, three years after the last case was reported in Junín, Peru. A global polio eradication initiative was launched in 1988 and has reduced the incidence of polio worldwide by more than 99%. When it was launched in 1988, more than 350 000 children were paralyzed in more than 125 endemic countries. In 2009, 1 595 children were paralyzed in 24 countries. Today, only four countries remain endemic: Afghanistan, India, Nigeria, and Pakistan and in those countries with endemic poliovirus transmission, cases of poliomyelitis had declined by 85% in 2010 compared to the same period in 2009.

**sharon sanders** · January 26, 2011, 04:11 PM

Re: Haiti - PAHO/WHO investigating at least three cases of paralysis in cholera patients

Apparently PAHO/WHO have been working on this situation before the submission to ProMED by Wil son:

"..PAHO/WHO field epidemiologists and local health authorities from the Department of Nord-Ouest first reported a cluster of acute neurological syndromes in that department January 10, 2011..."

**Tonka** · January 27, 2011, 11:00 AM

Re: Haiti: AFP outbreak

http://www.promedmail.org/pls/otn/f?..._ID:1000,86845

Archive Number 20110127.0317
Published Date 27-JAN-2011
Subject PRO/EDR> Acute flaccid paralysis - Haiti (03): ODS, PAHO
ACUTE FLACCID PARALYSIS - HAITI (03): OSMOTIC DEMYELINATION SYNDROME,
PAHO
************************************************** ******
A ProMED-mail post
<http: www.promedmail.org="">
ProMED-mail is a program of the
International Society for Infectious Diseases
<http: www.isid.org="">

In this update:
[1] PAHO/WHO news release
[2] Comment

******
[1] PAHO/WHO news release
Date: Wed 26 Jan 2011
Source: Pan American Health Organization (PAHO) press release
[edited]
<http: new.paho.org="" hq="" index.php?option="com_content&task=view&id=4646&It emid=1926">

PAHO/WHO investigating paralysis cases in Port-de-Paix, Haiti
-------------------------------------------------------------
Officials from the Pan American Health Organization/World Health
Organization (PAHO/WHO), along with colleagues from Haiti's Ministry
of Health and the US Centers for Disease Control and Prevention (CDC),
are looking into 4 cases of paralysis in recovering cholera patients
in Port-de-Paix, Haiti and, pending laboratory results, are likely to
rule out polio as a cause.

Experts including toxicologists are investigating possible
contamination at a hospital or at home from medication, food or
another source as the cause of death in these cases. PAHO and CDC
officials are conducting field studies and will report their findings
as soon as laboratory results are available.

Polio was one of the 1st possibilities looked into because of the
public health implications. However, the clinical characteristics and
epidemiology of these cases make poliomyelitis a remote possibility;
in simple terms, polio does not produce a high mortality rate.
Although considered highly unlikely, polio has not been completely
ruled out, pending laboratory results of samples.

PAHO/WHO has suggested that health officials remain vigilant for
further cases and has supported local health authorities in the
investigation with technical staff including epidemiologists, a
clinician and an immunization nurse to continue the investigations. A
nurse who works with PAHO/WHO's immunization program returned from
visiting the affected communities Monday [24 Jan 2011] with samples
from some of the families. A PAHO/WHO clinician and a PAHO/WHO
immunization advisor are participating in the investigation.

PAHO/WHO field epidemiologists and local health authorities from the
Department of Nord-Ouest first reported a cluster of acute
neurological syndromes in that department [10 Jan 2011]. As of [24 Jan
2011], 4 cases with acute neurological syndrome, including 3 deaths,
were reported, with dates of onset from November to December 2010 in
the La Pointe area, Commune Port-de-Paix, and the neighboring commune
of Saint Louis du Nord. All of the cases were seen at the same cholera
treatment center and returned 2-4 days later with neurological
symptoms, at which point they were hospitalized.

Working with the Director of the Department of Nord-Ouest and local
officials, interviews with medical staff and relatives showed that the
patients were admitted to the hospital between early November and the
end of December [2010]. These patients, hospitalized for severe
cholera, presented an ascending bilateral flaccid paralysis of acute
onset 24 to 72 hours after the end of the cholera treatment. No
additional cases were detected after the initial field investigation
in the Nord-Ouest Department. Samples of blood, feces, and CSF were
taken from one patient, and laboratory results are still pending.
PAHO/WHO field epidemiologists and local health authorities notified
the central Alerts and Response Unit of these cases [10 Jan 2011].

Of the suspected cases, only 4 had symptoms and signs compatible with
paralysis. 3 have died, and one is hospitalized in Port-au-Prince. He
is recovering slowly. As a prudent measure, polio vaccine has been
added to an upcoming vaccination campaign against diphtheria and
measles in the Nord-Ouest Department.

Polio was eradicated from the Americas in 1994, 3 years after the
last case was reported in Junin, Peru. A global polio eradication
initiative was launched in 1988 and has reduced the incidence of polio
worldwide by more than 99 percent. When it was launched in 1988, more
than 350 000 children were paralyzed in more than 125 endemic
countries. In 2009, 1595 children were paralyzed in 24 countries.
Today, only 4 countries remain endemic: Afghanistan, India, Nigeria,
and Pakistan and in those countries with endemic poliovirus
transmission, cases of poliomyelitis had declined by 85 percent in
2010 compared to the same period in 2009.

--
Communicated by:
Daniel B Epstein (WDC)
Information Officer
Pan American Health Organization/World Health Organization
<epsteind@paho.org>

******
[2]
Date: Wed 26 Jan 2011
From: Niklas Danielsson <niklas.danielsson@ecdc.europa.eu> [edited]

Re: ProMED-mail Acute flaccid paralysis - Haiti (02): ?post cholera,
RFI 20110125.0307]
----------------------------------------------------------------------
Having read the description by Dr James Wil son on ProMED-mail [22 Jan
2011] of a group of cholera patients in Haiti who developed acute
flaccid paralysis during the recovery phase after receiving treatment
for severe dehydration/hypovolemic shock, I would propose a possible
differential diagnosis. The symptoms he describes fit a rare but well
described condition called osmotic demyelination syndrome (ODS). The
syndrome has high mortality and is associated with intravenous
correction of hyponatremia. Cholera itself, as well as oral and IV
rehydration treatment for cholera, can result in hyponatremia. A
typical feature of ODS is the biphasic presentation. Patients
initially respond well to the treatment for dehydration and
hyponatremia but later deteriorate rapidly. The patients described by
Dr Wil son first recovered, but then deteriorated within 72 hours.
Classical symptoms include symmetrical quadriplegia, dysarthria,
dysphagia, confusion, and pseudobulbar palsy. Hyponatremia seems to be
the common denominator for ODS which is also linked to chronic
alcoholism, liver disease, malnutrition, psychogenic polydipsia, and
post-surgery.

--
Niklas Danielsson
Senior expert communicable diseases
Scientific communication section
Country Cooperation and Communication Unit (CCU), ECDC
<niklas.danielsson@ecdc.europa.eu>

[[The news release from PAHO above mentions 4 identified cases with
an acute neurologic syndrome within 24 to 72 hours following treatment
for cholera in the Nord-Ouest Department of Haiti. In the prior
ProMED-mail report on this event there was mention of a possible 7
cases (see Acute flaccid paralysis - Haiti (02): ?post cholera, RFI
20110125.0307) under investigation. In the early stages of
identification of an outbreak, it is not uncommon to hear differing
case counts from different sources often reflecting different
reporting sources of information and often different case definitions.
At this point in time, pending results of the thorough investigations
underway, one cannot rule in or out a possible infectious etiology or
toxic exposure.

The mention of the osmotic demyelination syndrome [ODS] by Dr
Danielsson (see [2] above) is very interesting. A literature search
revealed the 1st discussion of a post hyponatremia treatment
associated demyelination by Kleinschmidt-DeMasters BK, Norenberg MD in
Science in 1981 (ref 1). The 1st published article referring to this
syndrome specifically referred to as osmotic demyelination syndrome
was by Sterns, Riggs, and Schochet in the NEJM in 1986 (ref 4).
Reviewing the references available, most of the publications refer to
single occurrences or small groups of patients identified, supporting
Dr Danielsson's mention that this is a rare syndrome and is associated
with a rapid increase in sodium following a severe hyponatremia. The
clinical description of the presentation of ODS (well summarized by Dr
Danielsson) is compatible with the presentation of the cases in Haiti
reported by Dr Wil son in the 2 prior ProMED-mail reports. It is
curious that it has not been described in the literature in
association with cholera outbreaks elsewhere in the world.

We await further information on the results of the pending laboratory
studies and further epidemiologic investigations.

ProMED-mail would also like to thank Viki Hansen-Landis and
ProMED-mail Rapporteur Mary Marshall for submitting the same PAHO/WHO
news release.

For the interactive HealthMap/ProMED map of Haiti, see
<http: healthmap.org="" r="" 00yn="">.

References
----------
1. Kleinschmidt-DeMasters BK, Norenberg MD: Rapid correction of
hyponatremia causes demyelination: relation to central pontine
myelinolysis. Science. 1981 Mar 6; 211(4486): 1068-70 [abstract
available at <http: www.ncbi.nlm.nih.gov="" pubmed="" 7466381="">].
2. Laureno R: Central pontine myelinolysis following rapid correction
of hyponatremia. Ann Neurol. 1983 Mar; 13(3): 232-42 [abstract
available at <http: www.ncbi.nlm.nih.gov="" pubmed="" 6847135="">].
3. Norenberg MD, Leslie KO, Robertson AS: Association between rise in
serum sodium and central pontine myelinolysis. Ann Neurol. 1982 Feb;
11(2): 128-35 [abstract available at
<http: www.ncbi.nlm.nih.gov="" pubmed="" 7073246="">].
4. Sterns RH, Riggs JE, Schochet SS Jr: Osmotic demyelination
syndrome following correction of hyponatremia. N Engl J Med. 1986 Jun
12; 314(24): 1535-42 [abstract available at
<http: www.nejm.org="" doi="" full="" 10.1056="" nejm198606123142402="">].
5. King JD, Rosner MH: Osmotic demyelination syndrome. Am J Med Sci.
2010 Jun; 339(6): 561-7 [abstract available at
<http: www.ncbi.nlm.nih.gov="" pubmed="" 20453633="">]. - Mod.MPP]]

[see also:
Acute flaccid paralysis - Haiti (02): ?post cholera, RFI
20110125.0307
Acute flaccid paralysis - Haiti: RFI 20110121.0256
.................................................m pp/mj/jw
*################################################# #########*
************************************************** **********
ProMED-mail makes every effort to verify the reports that
are posted, but the accuracy and completeness of the
information, and of any statements or opinions based
thereon, are not guaranteed. The reader assumes all risks in
using information posted or archived by ProMED-mail. ISID
and its associated service providers shall not be held
responsible for errors or omissions or held liable for any
damages incurred as a result of use or reliance upon posted
or archived material.
************************************************** **********
Donate to ProMED-mail. Details available at:
<http: www.isid.org="" promedmail_donations.shtml="">
************************************************** **********
Visit ProMED-mail's web site at <http: www.promedmail.org="">.
Send all items for posting to: promed@promedmail.org (NOT to
an individual moderator). If you do not give your full name
name and affiliation, it may not be posted. You may unsub-
scribe at <http: www.isid.org="" promedmail="" subscribe.lasso="">.
For assistance from a human being, send mail to:

.
################################################## ##########
################################################## ##########</postmaster@promedmail.org></http:></http:></http:></http:></http:></http:></http:></http:></http:></niklas.danielsson@ecdc.europa.eu></niklas.danielsson@ecdc.europa.eu></epsteind@paho.org></http:></http:></http:>

**alert** · January 27, 2011, 12:46 PM

Re: Haiti - PAHO/WHO investigating at least 3 cases of paralysis in cholera patients - possible Osmotic Demyelination Syndrome, surviving patient tests negative for polio

http://www.google.com/hostednews/ap/...b718da9177ee52

Officials test for, but doubt, polio in Haiti
(AP) ? 14 hours ago

PORT-AU-PRINCE, Haiti (AP) ? Health officials are looking into the cases of four people who became paralyzed in northwestern Haiti while recovering from cholera.

The experts are trying to determine if the patients in Port-de-Paix were sickened by polio.

Local health authorities reported suspected cases on Jan. 10. Of four showing paralysis three died and one is hospitalized in the capital.

Officials from the Pan American Health Organization, Haiti's Ministry of Health and U.S. Centers for Disease Control and Prevention say they doubt polio is the cause.

PAHO spokeswoman Nyka Alexander says the surviving patient has tested negative for that disease.

But PAHO says polio vaccine was added to an upcoming vaccination campaign against diphtheria and measles in the area as a "prudent measure."

**alert** · January 27, 2011, 01:09 PM

Re: Haiti - PAHO/WHO investigating at least 3 cases of paralysis in cholera patients - possible Osmotic Demyelination Syndrome

This is the YouTube video referred to in the first ProMED post. I believe the case being transferred is #4, the one that is still alive.

http://www.youtube.com/watch?v=LAlAIowUKTg

**sharon sanders** · January 27, 2011, 01:32 PM

Re: Haiti - PAHO/WHO investigating at least 3 cases of paralysis in cholera patients - possible Osmotic Demyelination Syndrome

Thanks Alert. Looks like a coordination going on internationally by January 9, 2011 which is the date of this video post on youtube:

"Patient flown to Port Au Prince from Northern Haiti Via Medical Teams International and MFI. The patient was recieved by Global DIRT with IMAT (International Medical Assistance Team) staff. The patient was transfered to Medishare hospital and is currently on life support."

**sharon sanders** · January 28, 2011, 08:14 AM

Re: Haiti - PAHO/WHO investigating cases of paralysis in cholera patients - possible Osmotic Demyelination Syndrome

hat tip Crof -

Polio ruled out in Haitian patients' paralysis

Lab tests show that four Haitian patients treated for cholera do not have polio, but tests continue.

By JACQUELINE CHARLES

jcharles@MiamiHerald.com

PORT-AU-PRINCE -- Four Haitian cholera patients who were mysteriously paralyzed after treatment for the waterborne-disease do not have polio, said a Haitian epidemiologist.

Read more: http://www.miamiherald.com/2011/01/2...#ixzz1CKqWr96X

**alert** · January 31, 2011, 12:26 PM

Re: Haiti - PAHO/WHO investigating cases of paralysis in cholera patients - possible Osmotic Demyelination Syndrome

http://www.newscientist.com/article/...f-cholera.html

Haiti polio scare may be rare complication of cholera
16:41 31 January 2011 by Debora MacKenzie
Finally, some good news for Haiti: after three months, the cholera epidemic is starting to subside. And fears that polio had broken out may have been premature. A handful of people with polio-like symptoms may instead have had a previously unreported complication of cholera treatment.

snip

Rare imbalance
If the concentration of sodium in blood falls, more water flows into cells by osmosis, causing them to swell. Nerves cells in the brain can be damaged if the glial cells that form the myelin sheaths around them swell.

If osmotic pressure persists, glial cells protect against this damage by reducing their own internal osmotic pressure so that they don't swell. However, if blood salt returns to normal quickly, the glial cells cannot adapt back fast enough. The normal osmotic pressure shrinks the cells, destroying them, says Rosner.

Both cholera and rehydration treatment cause low blood sodium which can last for several days, says Danielsson. ODS could be triggered when the blood returns to normal after treatment stops. An MRI scan of neural tissue could settle it, says Rosner, as ODS causes typical patterns of damage.

It's a devastating diagnosis for the people involved – but the good news for Haiti is that, unlike polio, ODS isn't infectious.

**alert** · February 1, 2011, 09:52 AM

Re: Haiti - PAHO/WHO investigating cases of paralysis in cholera patients - possible Osmotic Demyelination Syndrome

Obviously, if you are going to examine every AFP case in an entire country over a period of several months, you are likely to find a variety of causes unrelated to the investigation.

It would be nice to know which cases are likely ODS, and which may be due to GBS or some other cause. The wider a net you cast in looking for something, the more incidental cases you find. It seems the original hypothesis of polio, either wild or vaccine-derived, has been excluded.

http://haiti.mphise.net/causes-paralysis-cases

Lionel,

The original ProMed post on Osmotic Demyelination Syndrome was added in the Paralysis Cases Investigation working group of the Haiti MPHISE 4 or 5 days ago.

You can view it on the front page at:

http://haiti.mphise.net/

Some of the 11 paralysis cases fit iatrogenic Osmotic Demyelination Syndrome caused by rapid rehydration of hyponatremia cases, first presenting with cholera. However, the superset of 11 cases does not. Some of these cases may be Guillain-Barre syndrome (GBS). Others do not look like GBS. More detailed analysis and lab work must be completed before we know what this pattern , or patterns of disease, is caused from.

I would like to have three volunteers to join the Haiti MPHISE Paralysis Cases Investigation working group, that will work on clarifying the line lists and details of the cases that are emerging. Please let me know if you have an interest in this.

Mike

Michael D. McDonald, Dr.P.H.

President
Global Health Initiatives, Inc.

Coordinator
Haiti MPHISE http://haiti.mphise.net/

Haiti Resilience System http://www.haitiresiliencesystem.org/
Haiti MPHISE UDOP http://haiti.youdop.org/

Cell: 202-468-7899
Michael.D.McDonald@mac.com

On Jan 31, 2011, at 3:35 PM, lionelstpierre@gmail.com wrote:

> I bumped into this... Best
> Lionel
>
> Haiti polio scare may be rare complication of cholera. Niklas Danielsson of the European Centre for Disease Control and Prevention in Stockholm, Sweden, says this suggests osmotic demyelination syndrome (ODS). http://www.newscientist.com/mobile/a...olio-scare-may...
> Sent from my BlackBerry® device from Digicel

**alert** · February 1, 2011, 11:37 AM

Re: Haiti - PAHO/WHO investigating cases of paralysis in cholera patients - possible Osmotic Demyelination Syndrome

As to the level of background noise, Haiti has only reported 1-5 AFP cases total per year for the past few years. Mexico, a country roughly 10 times the population, has reported 400-500. Neither country has reported any polio. One might thus expect the true background AFP count per year in Haiti to be 40-50 cases, so the level of background noise (and ODS is NOT background noise) may bery well be louder than the entire "outbreak".

http://apps.who.int/immunization_mon...afpextract.cfm

**alert** · February 4, 2011, 05:32 PM

Re: Haiti - PAHO/WHO investigating cases of paralysis in cholera patients - possible Osmotic Demyelination Syndrome

http://www.reliefweb.int/rw/rwb.nsf/...ull_report.pdf

[snip]

Experts are investigating the possibility that the four cases of paralysis in cholera patients in the Northwest
department may originate from medicines, food or other sources. It is likely that polio will be dismissed as the
cause of these cases.

**alert** · February 6, 2011, 11:04 AM

Re: Haiti - PAHO/WHO investigating cases of paralysis in cholera patients - possible Osmotic Demyelination Syndrome

http://new.paho.org/hq/index.php?opt...18&Itemid=1926

[snip]

Washington, DC, February 4, 2011 (PAHO/WHO) ? The Pan American Health Organization/World Health Organization (PAHO/WHO) is urging all international travelers to Haiti to get up-to-date on their vaccines, to ensure they do not unknowingly import infectious diseases into Haiti.

The recommendation follows recent epidemiological investigations of two disease outbreaks in Haiti, one involving suspected polio and the other, suspected measles. The investigations were carried out by Haiti?s Ministry of Health with support from PAHO/WHO and the U.S. Centers for Disease Control and Prevention (CDC).

The first investigation concerned four cases of paralysis in cholera patients in the coastal city of Port-de-Paix. Laboratory tests have ruled out polio as the cause of the illnesses. However, as a precaution, polio vaccine is now being included in vaccination campaigns against diphtheria and measles in the area. No cases of indigenous wild polio have been reported in Haiti since polio was declared eradicated from throughout the Americas in 1994.