Att D-4_Acute Flaccid Myelitis

Acute Flaccid Myelitis: Patient Summary Form

FOR LOCAL USE ONLY

Name of person completing form: ______________________________________________ State assigned patient ID: _______________________

Affiliation__________________________________ Phone: ____________________________Email: _____________________________________

Name of physician who can provide additional clinical/lab information, if needed ______________________________________________________

Affiliation_____________________________________ Phone: ___________________________ Email: ___________________________________

Name of main hospital that provided patient’s care: ___________________________________ State: _____ County: ______________________

Form Approved

OMB No. 0920-0009

Exp Date: 04/30/2016

-------------------------------------------------------------DETACH and transmit only lower portion to limbweakness@cdc.gov if sending to CDC-------------------------------------------------------------

Acute Flaccid Myelitis: Patient Summary Form

Form to be completed by, or in conjunction with, a physician who provided care to the patient during the neurological illness. Once completed, submit to Health Department (HD). HD can also facilitate specimen testing.

1. Today’s date__ __/__ __/__ __ __ __ (mm/dd/yyyy) 2. State assigned patient ID: ________________________________________

3. Sex:  M F 4. Date of birth __ __/ __ __/ __ __ __ __ Residence: 5. State_______ 6. County_____________________________

7. Race: American Indian or Alaska Native Asian Black or African American 8. Ethnicity: Hispanic or Latino

Native Hawaiian or Other Pacific Islander White (check all that apply) Not Hispanic or Latino

9. Date of onset of limb weakness __ __/__ __/__ __ __ __ (mm/dd/yyyy) 10. Was patient admitted to a hospital? yes no unknown 11.Date of admission to first hospital__ __/__ __/__ __ __ __ 12.Date of discharge from last hospital__ __/__ __/__ __ __ __(or  still hospitalized at time of form submission)

13. Did the patient die from this illness? yes no unknown 14. If yes, date of death__ __/__ __/__ __ __

SIGNS/SYMPTOMS/CONDITION:
	Right Arm	Left Arm	Right Leg			Left Leg
15. Since neurologic illness onset, which limbs have been acutely weak? [indicate yes(y), no (n), unknown (u) for each limb]	Y N U	Y N U	Y N U			Y N U
16. Date of neurologic exam (recorded at most severe weakness to point of completing this form) (mm/dd/yyyy)	__ __ /__ __/__ __ __ __
17. At the time of most severe weakness, reflexes in the most affected limb(s):	 Areflexic/hyporeflexic (0-1)  Normal (2)  Hyperreflexic (3-4+)
At ANY time during the illness, was there:
18. Any sensory loss/numbness in the affected limb(s), at any time during the illness? (paresthesias should not be considered here)	Y N U
19. Any pain or burning in the affected limb(s)?	Y N U
				Yes	No	Unk/Not Recorded (NR)
20. Sensory level on the torso (i.e., reduced sensation below a certain level of the torso)?
21. Did patient have any of the cranial nerve features below? (If yes, check all that apply):
Diplopia/double vision (If yes, circle the cranial nerve involved if known: 3 / 4 / 6 )
Loss of sensation in face  Facial droop Hearing loss  Dysphagia  Dysarthria
22. Bowel or bladder incontinence?
23. Change in mental status (e.g., confused, disoriented, encephalopathic)?
24. Seizure(s)?
25. Receipt of positive pressure ventilation, including invasive or non-invasive ventilation and including BiPAP or CPAP?

Other patient information:

In the 4-weeks BEFORE onset of limb weakness, did patient:	Yes	No	Unk/NR
26. Have a respiratory illness?				27. If yes, onset date __ __/__ __/__ __ __ __
28. Have a gastrointestinal illness (e.g., diarrhea or vomiting)?				29. If yes, onset date __ __/__ __/ __ __ __ __
30. Have a new onset rash?				31. If yes, onset date __ __/__ __/__ __ __ __
32. Have a fever, measured by parent or provider and ≥ 38.0°C/100.4°F?				33. If yes, onset date __ __/__ __/__ __ __ __
34. Receive any immunosuppressing agent(s) (BEFORE WEAKNESS ONSET)?				Form Approved OMB No. 0920-0009 Exp Date: 04/30/2016 35. If yes: Date of first administration: __ __/ __ __ / __ __ __ __ Name of medication: _____________________ Mode of administration: IM IV Oral Dosage / duration / overall amount administered: _______________________________________
36. Travel outside the US?				37. If yes, list country:
38. At onset of limb weakness, does patient have any underlying illnesses?				39. If yes, list:
40. On the day of onset of limb weakness, did patient have a fever?				(see definition for fever above in 32.)

Polio vaccination history:
41. How many doses of inactivated polio vaccine (IPV) are documented to have been received by the patient before the onset of weakness?	_______doses unknown
42. How many doses of oral polio vaccine (OPV) are documented to have been received by the patient before the onset of weakness?	_______doses unknown
43. If you do not have documentation of the type of polio vaccine received what is total number of documented polio vaccine doses received before onset of weakness?	_______doses unknown

Neuroradiographic findings:

MRI of spinal cord 44. Was MRI of spinal cord performed?  yes no  unknown

45. If yes, how many documented spinal MRIs were performed? ________

If yes to Q44, complete Q46-Q71 based on most abnormal spine MRI 46. Date of most abnormal spine MRI __ __/__ __/__ __ __ __

47. Levels imaged: cervical thoracic lumbosacral unknown

48. Location of lesions:	cervical cord thoracic cord conus cauda equina unknown	Levels of cord affected (if applicable): 49. Cervical: _________ 50. Thoracic: _________
For cervical and thoracic cord lesions	51. What areas of spinal cord were affected?	predominantly gray matter predominantly white matter both equally affected  unknown
	52. Was there cord edema?	 yes no  unknown
53. Gadolinium (GAD) used: yes no  unknown (If NO, skip to question 59)
For cervical, thoracic cord or conus lesions	54. Did any gray matter lesions enhance with GAD?	 yes  no  unknown
	55. Did any white matter lesions enhance with GAD?	 yes  no  unknown
	56. Did any cervical / thoracic nerve roots enhance with GAD?	 yes  no  unknown
For cauda equina lesions	57. Did the ventral nerve roots enhance with GAD?	 yes  no  unknown
	58. Did the dorsal nerve roots enhance with GAD?	 yes  no  unknown

MRI of brain

59. Was brain/brainstem/cerebellum MRI performed?  yes no  unknown (If NO, skip to Q72) 60. Date of study __ __/__ __/__ __ __ __

61. Any supratentorial (i.e, lobe, cortical, subcortical, basal ganglia, or thalamic) lesions	 yes  no  unknown
	62.If yes, indicate location(s)	cortex basal ganglia thalamus  subcortex unknown Other (specify): ____________________
63. Any brainstem lesions?	 yes  no  unknown
	64. If yes, indicate location:	midbrain pons medulla unknown
65. Any cranial nerve lesions?	 yes  no  unknown
	66. If yes, indicate which CN(s):	CN_____ unilateral bilateral CN_____ unilateral bilateral
		CN_____ unilateral bilateral CN_____ unilateral bilateral
67. Any lesions affecting the cerebellum?	 yes  no  unknown
68. Gadolinium (GAD) used:  yes  no  unknown (If NO, skip to question 72)
69. Did any supratentorial lesions enhance with GAD?	 yes  no  unknown
70. Did any brainstem lesions enhance with GAD?	 yes  no  unknown
71. Did any cranial nerve lesions enhance with GAD?	 yes  no  unknown

72. Was an EMG done?  yes  no  unknown If yes, date __ __/__ __/__ __ __ __ (mm/dd/yyyy)

73. If yes, was there evidence of acute motor neuropathy, motor neuronopathy, motor nerve or anterior horn cell involvement?  yes  no  unk

CSF examination: 74. Was a lumbar puncture performed?  yes  no  unknown

If yes, complete 74 (a,b) (If more than 2 CSF examinations, list the first 2 performed)

	Date of lumbar puncture	WBC/mm3	% neutrophils	% lymphocytes	% monocytes	% eosinophils	RBC/mm3	Glucose mg/dl	Protein mg/dl
74a. CSF from LP1
74b. CSF from LP2

Pathogen testing performed:

75. Was CSF tested?  yes  no  unknown Specimen Collection Date __ __ / __ __/ __ __ __ __ If ‘yes’, was specimen tested for the following:
	Enterovirus  yes  no  unknown	Test Type	Test Result	Typed (if positive)?	Type
		PCR	 Positive  Negative  Pending	 yes  no  not done	_______
	West Nile Virus  yes  no  unknown	PCR	 Positive  Negative  Pending
	West Nile Virus  yes  no  unknown	IgM	 Positive  Negative  Indeterminate  Pending  Unknown
	Herpes simplex virus  yes  no  unknown	PCR	 Positive  Negative  Pending
	Cytomegalovirus  yes no  unknown	PCR	 Positive  Negative  Pending
	Varicella zoster virus  yes  no  unknown	PCR	 Positive  Negative  Pending
	Was other pathogen identified:  yes  no  unknown	If positive for other pathogen, specify test type: _____________	List other pathogen(s) identified:
76. Was a RESPIRATORY TRACT specimen tested?  yes  no  unknown Specimen Collection Date __ __ / __ __/ __ __ __ __ Type of specimen:  nasopharyngeal swab  nasal wash/aspirate  oropharyngeal swab  other, specify: ________________________ If ‘yes’, was specimen tested for the following:
	Enterovirus/rhinovirus  yes  no  unknown	Test Type	Test Result	Typed (if positive)?	Type
		PCR	 Positive  Negative  Pending	 yes  no  not done	_______
	Adenovirus  yes  no  unknown	PCR	 Positive  Negative  Pending	 yes  no  not done	_______
	Influenza virus  yes  no  unknown	PCR	 Positive  Negative  Pending	 yes  no  not done	_______
	Was other pathogen identified:  yes  no unknown	If positive for other pathogen, specify test type: _____________	List other pathogen(s) identified:
77. Was a STOOL specimen tested?  yes  no  unknown Specimen Collection Date __ __ / __ __/ __ __ __ __ If ‘yes’, was specimen tested for the following:
	Non-polio Enterovirus  yes  no  unknown	Test Type	Test Result	Typed (if positive)?	Type
		PCR	 Positive  Negative  Pending	 yes  no  not done	_______
	Poliovirus  yes  no  unknown	PCR	 Positive  Negative  Pending
	Poliovirus  yes  no  unknown	Culture	 Positive  Negative  Pending
	Was other pathogen identified:  yes  no unknown	If positive for other pathogen, specify test type: _____________	List other pathogen(s) identified:
78. Was SERUM tested?  yes  no  unknown Specimen Collection Date __ __ / __ __/ __ __ __ __ If ‘yes’, was specimen tested for the following:
	West Nile Virus  yes  no  unknown	Test Type	Test Result	Typed (if positive)?	Type
		PCR	 Positive  Negative  Pending
	West Nile Virus  yes  no  unknown	IgM	 Positive  Negative  Indeterminate  Pending  Unknown
	Was other pathogen identified:  yes  no unknown	If positive for other pathogen, specify test type: _____________	List other pathogen(s) identified:

79. Was/Is a specific etiology considered to be the most likely cause for the patient’s neurological illness?  yes  no  unknown 80. If yes, please list etiology and reason(s) considered most likely cause ____________________________________________________________

_______________________________________________________________________________________________________________________

81. If patient is a confirmed or probable case, will specimens be sent to CDC for testing?  yes  no  unknown

82. If yes, types of specimens that will be sent to CDC for testing:

 CSF  Nasal wash/aspirate BAL spec Tracheal aspirate NP/OP swab Stool Serum  Other, list __________________

Acute Flaccid Myelitis case definition (http://c.ymcdn.com/sites/www.cste.org/resource/resmgr/2015PS/2015PSFinal/15-ID-01.pdf)

Criteria

An illness with onset of acute focal limb weakness AND

● a magnetic resonance image (MRI) showing spinal cord lesion largely restricted to gray matter and spanning one or more spinal segments, OR

● no spinal cord MRI performed but cerebrospinal fluid (CSF) with pleocytosis (white blood cell count >5 cells/mm³)

Case Classification

Confirmed:

● An illness with onset of acute focal limb weakness AND

● MRI showing spinal cord lesion largely restricted to gray matter and spanning one or more spinal segments

Probable:

● An illness with onset of acute focal limb weakness AND

● No spinal cord MRI performed but CSF showing pleocytosis (white blood cell count >5 cells/mm³).

Public reporting burden of this collection of information is estimated to average 30 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74 Atlanta, Georgia 30333.

Page 1 of 5 Version 4.0 September 28, 2015