Acute flaccid paralysis in a patient with sacral dimple

Table 1 Common causes of acute flaccid paralysis in infants and children

Type of lesion	Common presenting features	Site of Lesion	Causes	Clues for diagnosis
UMNL	AFP and hypotonia are initial presentations for UMNL AFP occurs on the opposite side of the central nervous system lesion Spasticity develops later with hyper-reflexia and positive Babinski sign	Cerebral cortex	Intracranial hemorrhage	History of trauma
				Signs of increased intra-cranial tension
				Signs of lateralization
			Brain tumor	History of known brain tumor
				Signs of increased intra-cranial tension
			Seizure	Todd paralysis following seizure activity
			Hypoxic ischemic encephalopathy	History of perinatal asphyxia
		Spinal cord	Spinal cord trauma	Trauma
				Sensory loss/level
				Early bowel/bladder
				involvement
				Spinal tenderness,
				painful spine
				movement
			Spinal cord tumor	Sensory loss/level
				Early bowel/bladder
				involvement
				Spinal tenderness,
				painful spine
				movement
			Paraspinal infection or inflammation	Fever
				Sensory loss/level
				Early bowel/bladder
				involvement
				Spinal tenderness,
				painful spine
				movement
			Transverse myelitis	Fever
				Sensory loss/level
				Early bowel/bladder
				involvement
				Neck stiffness
LMNL	AFP and hypotonia are persistent presentations for LMNL Muscle weakness Hypotonia Fasciculations Decreased spinal cord reflexes	Anterior horn cell disease	Poliomyelitis	Fever
				Preceding intramuscular injection
				Neck stiffness
			Non Poliomyelitis Eneroviruses	Fever
			Enterovirus type 71	Hand-foot-mouth disease with enterovirus type 71 and Coxsackie infections
			Coxsackie viruses	Myocarditis and/or hepatitis
			Echoviruses	Parotitis
			Mumps virus
		Peripheral Nerve	Guillain-Barré syndrome	Preceding infectious
				prodrome/vaccination
				Prominent autonomic
				signs/symptoms
				Ascending weakness
				Facial weakness
				Myalgia
				Neck stiffness
			Peripheral nerve toxins	Exposure
			Acute intermittent porphyria	Intermittent nature
				Abdominal pain
				Peripheral neuropathies
				Central nervous system signs (seizures, mental status changes, cortical blindness, and coma)
		Neuromuscular junction disorders	Botulism	Exposure
				Constipation
				Descending weakness
				Facial weakness
			Myasthenia gravis	Prominent and early
				ptosis
				Facial weakness
				Fluctuating symptoms,
				fatigability
			Organophosphate poisoning	Exposure
				Myosis
				muscle fasciculation
			Neurotoxic snake envenomation	Exposure
				Site of bite
		Muscle	Rhabdomyolysis	Muscle tenderness
			Myositis	Fever
				Muscle tenderness
			Familial periodic paralysis	Preserved muscle stretch reflexes
		Others	Electrolyte disturbance	Diarrhea
			Drug-related	Exposure

AFP: Acute flaccid paralysis; UMNL: Upper motor neuron lesions; LMNL: Lower motor neuron lesions.