Acute Neurological Illness with Limb Weakness in Childre

Form Approved

OMB No. 0920-0009

Exp Date: 04/30/2016

CDC ID ______________

PART I. Acute Neurological Illness with Limb Weakness in Children: Patient Summary Form

Form to be completed by, or in conjunction with, a physician who provided care to the patient during the neurological illness.

Confirmation of case:	Yes	No	Unknown
a. Neurological findings (upon examination by clinician) include focal limb weakness
b. MRI of spinal cord demonstrates spinal lesion(s) largely restricted to or predominantly affecting the gray matter. (Terms in the spinal cord MRI report such as “affecting mostly gray matter,” “affecting the anterior horn or anterior horn cells,” “affecting the central cord,” “anterior myelitis,” or “poliomyelitis” would all be consistent with this. If still unsure if this criterion is met, consider asking the radiologist directly.)
c. Age at onset of limb weakness is 21 years or less
d. Onset of limb weakness was August 1, 2014 or later

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Answer to ALL 4 criteria must be YES. If yes, continue to Part II on pages 2 - 5.

If you have any questions about whether your patient meets all 4 criteria, please e-mail us at [email protected]

CDC ID ______________

PART II. Acute Neurological Illness with Limb Weakness in Children: 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.Name of person completing form: ______________________________________________

3. Affiliation____________________________________Phone: ____________________________Email: __________________________________

4. Name of physician who can provide additional clinical/lab information, if needed _____________________________________________________

5. Affiliation_____________________________________ Phone: ___________________________ Email: __________________________________

6. Name of main hospital that provided patient’s care:____________________________________ 7.State: _____ 8.County: __________________

9. Patient ID: ________________________________10. State ID: ________________________________________ 11. Patient’s sex:  M F 12. Patient’s age: ______years AND _______months Patient’s residence: 13. State_______ 14. County____________________________

15. Race: Asian Black or African American Native Hawaiian or Other Pacific Islander American Indian or Alaska Native

White (check all that apply) 16. Ethnicity: Hispanic Non-Hispanic

17. Date of onset of limb weakness: __ __/__ __/__ __ __ __ (mm/dd/yyyy) 18. Was patient admitted to a hospital? yes no unknown 19.Date of admission to first hospital__ __/__ __/__ __ __ __ 20.Date of discharge from last hospital__ __/__ __/__ __ __ __(or  still hospitalized)

21. At the time of last / most recent follow-up, how would you best characterize the patient’s outcome, in terms of affected limb strength:  Completely recovered; back to baseline strength with no residual sequelae  Partially recovered; some improvement in limb strength, but with ongoing weakness compared to initial presentation  No demonstrable improvement in limb strength; essentially as weak as at time of first presentation  Decline in limb strength; weaker in affected limbs than at time of first presentation  Unknown / unable to comment  Deceased: 22.Date of death__ __/__ __/__ __ __

23. At the time of last / most recent follow-up, how would you best characterize the patient’s functional outcome, in terms of effect of limb weakness on activities of daily living? (Not applicable if Q21 is ‘Deceased’)

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 Completely functionally recovered; able to do all activities as prior to acute illness  Somewhat functionally impaired; able to do some activities on own, but needs caregiver assistance with other things (dressing, tying shoes, feeding, etc.)  Completely dependent on caregiver for basic daily functions

Signs/symptoms/condition at ANY time during the illness:
	Right Arm	Left Arm	Right Leg			Left Leg
24. 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
25. Date of neurologic exam (recorded at worst weakness thus far) (mm/dd/yyyy)	__ __ /__ __/__ __ __ __
26. Reflexes in the affected limb(s): (recorded at worst weakness thus far)	 Areflexic/hyporeflexic (0-1)  Normal (2)  Hyperreflexic (3-4+)
27. Any sensory loss/numbness in the affected limb(s), at any time during the illness? (paresthesias should not be considered here)	Y N U
28. Any pain or burning in the affected limb(s)? (at any time during illness)	Y N U	Y N U	Y N U			Y N U
				Yes	No		Unknown
29. Sensory level on the torso (ie, reduced sensation below a certain level of the torso)? (at any time during illness)
30. At any time during the illness, please check if the patient had any of the following cranial nerve signs:
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
31. Any pain or burning in neck or back? (at any time during illness)
32. Bowel or bladder incontinence? (at any time during illness)
33 .Cardiovascular instability (e.g, labile blood pressure, alternating tachy/bradycardia)? (at any time during illness)
34. Change in mental status (e.g, confused, disoriented, encephalopathic)? (at any time during illness)
35. Seizure(s)? (at any time during illness)
36. Received care in ICU because of neurological condition? (at any time during illness)
37. Received invasive ventilatory support (e.g, intubation, tracheostomy) because of neurological condition?

CDC ID ______________

Other patient information:

Within the 4-week period BEFORE onset of limb weakness, did patient:	Yes	No	Unk
38. Have a respiratory illness?				39. If yes, date of onset __ __/__ __/__ __ __ __
40. Have a fever, measured by parent or provider and ≥ 38.0°C/100.4°F?				41. If yes, date of onset __ __/__ __/__ __ __ __
42. Receive oral, IM or IV steroids?
43. Receive any other systemic Immunosuppressant(s)?				44. If yes, list:
45. Travel outside the US?				46. If yes, list country
47. Does patient have any underlying illnesses?				48. If yes, list
49. On the day of onset of limb weakness, did patient have a fever? (see definition above)

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

Neuroradiographic findings: (Indicate based on most abnormal study)

MRI of spinal cord 53. Date of study __ __/__ __/__ __ __ __ (mm/dd/yyyy)

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

55. Gadolinium used? yes no unknown

56. Location of lesions:	cervical cord thoracic cord conus cauda equina unknown	Levels of cord affected (if applicable): 57. Cervical: _________ 58. Thoracic: _________
For cervical and thoracic cord lesions	59. What areas of spinal cord were affected?	predominantly gray matter predominantly white matter both equally affected unknown
	60. Was there cord edema?	yes no unknown
For cervical, thoracic cord or conus lesions	61. Did any lesions enhance with GAD?	yes no unknown
For cauda equina lesions	62. Did the ventral nerve roots enhance with GAD?	yes no unknown
	63. Did the dorsal nerve roots enhance with GAD?	yes no unknown

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CDC ID ______________

MRI of brain 64. Date of study __ __/__ __/__ __ __ __ (mm/dd/yyyy)

65. Gadolinium used?  yes no unknown

66. Any supratentorial (i.e, lobe, cortical, subcortical, basal ganglia, or thalamic) lesions	yes no unknown
	67.If yes, indicate location(s)	cortex subcortex basal ganglia thalamus unknown
	68. If yes, did any lesions enhance with GAD?	yes no unknown
69. Any brainstem lesions?	yes no unknown
	70. If yes, indicate location:	midbrain pons medulla unknown
	71. If yes, did any lesions enhance with GAD?	yes no unknown
72. Any cranial nerve lesions?	yes no unknown
	73. If yes, indicate which CN(s):	CN_____ unilateral bilateral CN_____ unilateral bilateral
		CN_____ unilateral bilateral CN_____ unilateral bilateral
	74. If yes, did any lesions enhance with GAD?	yes no unknown
75. Any lesions affecting the cerebellum?	yes no unknown

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

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

CSF examination: 78. Was a lumbar puncture performed? yes no unknown If yes, complete 79 (If more than 2 CSF examinations, list earliest and then most abnormal)

	Date of lumbar puncture	WBC/mm3	% neutrophils	% lymphocytes	% monocytes	% eosinophils	RBC/mm3	Glucose mg/dl	Protein mg/dl
79a. CSF from LP1
79b. CSF from LP2

Pathogen testing performed:

80. Was CSF tested for the following pathogens?	Date of specimen collection __ __/__ __/__ __ __ __  Not done
	Enterovirus PCR:  Positive  Negative  Not done If positive: type:  Not typed
	West Nile Virus PCR:  Positive  Negative  Not done If positive, test type:  IgM  PCR
	Herpes Simplex Virus PCR:  Positive  Negative  Not done
	Cytomegalovirus PCR:  Positive  Negative  Not done
	Varicella Zoster Virus PCR:  Positive  Negative  Not done
	Other pathogen identified: specify: Type of test:

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CDC ID ______________

81. Was a respiratory tract specimen tested for the following pathogens?	Date of specimen collection __ __/__ __/__ __ __ __  Not done
	Enterovirus/rhinovirus PCR:  Positive  Negative  Not done If positive: type:  Not typed
	Adenovirus PCR:  Positive  Negative  Not done If positive: type:  Not typed
	Influenza virus PCR:  Positive  Negative  Not done If positive: type:  Not typed
	Other pathogen identified: specify: Type of test:

82. Was a stool specimen tested for the following pathogens?	Date of specimen collection __ __/__ __/__ __ __ __  Not done
	Enterovirus PCR:  Positive  Negative  Not done If positive: type:  Not typed
	Poliovirus PCR:  Positive  Negative  Not done
	Poliovirus culture:  Positive  Negative  Not done
	Other pathogen identified: specify: Type of test:

83. Was serum tested for the following pathogens?	Date of specimen collection __ __/__ __/__ __ __ __  Not done
	West Nile Virus:  Positive  Negative  Not done If positive, test type:  IgM  PCR
	Other pathogen identified: specify: Type of test:

84. Describe any other laboratory finding(s) considered to be significant_____________________________________________________________

_______________________________________________________________________________________________________________________

85. Was/Is a specific etiology considered to be the most likely cause for the patient’s neurological illness? yes no unknown 86. If yes, please list etiology and reason(s) considered most likely cause ____________________________________________________________

_______________________________________________________________________________________________________________________

Treatment: 87. Were any of these therapies administered for the acute neurologic illness? (as of time of form completion)

	Yes	No	Unknown
a. Antibiotics				If yes, date first administered: __ __/__ __/__ __
b. Antivirals				If yes, specify___________________; date first administered: __ __/__ __/
c. Corticosteroids				If yes, date first administered: __ __/__ __/__ __
d. Intravenous immune globulin (IVIG)				If yes, date first administered: __ __/__ __/__ __
e. Plasma exchange or Plasmapheresis				If yes, date first administered: __ __/__ __/__ __
f. Interferon				If yes, specify___________________; date first administered: __ __/__ __/
g. Other immunosuppressive therapy				If yes, specify___________________; date first administered: __ __/__ __/

88. Other information you would like us to know _______________________________________________________________________________

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_______________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________

89. Indicate which type(s) of specimens from the patient are currently stored, and could be available for possible additional testing at CDC:

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

 No specimens stored

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This section below for CDC use

CSID (DASH ID) _________________________		CSID (DASH ID) _________________________
CSID (DASH ID) _________________________		CSID (DASH ID) _________________________
CSID (DASH ID) _________________________		CSID (DASH ID) _________________________
CSID (DASH ID) _________________________		CSID (DASH ID) _________________________

Patient Number (assigned by CDC PPLB Lab)_________________________________________

State Specimen ID_______________________		State Specimen ID_______________________
State Specimen ID_______________________		State Specimen ID_______________________
State Specimen ID_______________________		State Specimen ID_______________________
State Specimen ID_______________________		State Specimen ID_______________________
Other specimen notes________________________________________________________________________________
__________________________________________________________________________________________________

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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;

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