CASE REPORT


Snake Eye Appearance; A Rare Radiology Presentation in Acute Flaccid Paralysis: A Case Report



Mohammad Vafaee-Shahi1, *, Roghayeh Saeedi2, Neda Pak3, Aina Riahi2, Saeide Ghasemi2
1 Pediatric Neurology, Pediatric Growth and Development Research center, Iran University of Medical Sciences, Tehran, Iran
2 Department of Pediatrics, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
3 Department of Radiology, Children Medical Center of Excellence, Tehran University of Medical Sciences, Tehran, Iran


© 2021 Vafaee-Shahi et al.

open-access license: This is an open access article distributed under the terms of the Creative Commons Attribution 4.0 International Public License (CC-BY 4.0), a copy of which is available at: https://creativecommons.org/licenses/by/4.0/legalcode. This license permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

* Address correspondence to this author at Pediatric Neurology, Pediatric Growth and Development Research center, Iran University of Medical Sciences, Tehran, Iran; Tel: +989133514636; +982166525328; Fax: 982166525328; E-mails: dr.vafaeeshahi@gmail.com; vafaeeshahi.m@iums.ac.ir


Abstract

Background:

Acute flaccid paralysis (AFP) is defined by the acute onset of weakness or paralysis with reduced muscle tone in children. There are many non-infectious and infectious causes. Snake eye appearance (SEA) is a rare radiologic appearance and helps narrow down differential diagnoses in flaccid paralysis.

Case Presentation:

Here, we reported a 6 months-old girl who was admitted with sudden onset flaccid paralysis. She was lethargic and ill without any detectable deep tendon reflexes. She had a high fever that had started 3 days earlier with malaise, poor feeding and coryza. The first child of the family was a boy who expired with similar symptoms; however, the reason is still unknown. Her parents were relatives (cousins). The laboratory and cerebrospinal fluid tests analysis were normal. The brain MRI analysis revealed T1 dim Hypo intensity and T2 hyperintensity along with obvious ADC map hyperintensity in the brain stem. At first, the PCR tests analysis of stool samples for poliovirus and enterovirus were normal. Spinal MRI showed snake eye appearance and helped us narrow our differential diagnosis. We repeated the PCR tests of stool because of snake eye appearance in cervical MRI that was positive for poliovirus and indicated vaccine-associated Paralytic Poliomyelitis (VAPP). Unfortunately, she expired from vaccine associated poliomyelitis.

Conclusion:

Snake eye appearance is a rare radiologic appearance that can be seen in several pathological conditions; however, it is very rare in patients with acute flaccid paralysis. Radiology signs, especially in spinal cord MRI, can help recognizing abnormalities in images, and narrow the list of differential diagnosis in acute flaccid paralysis. Therefore, spinal cord MRI has an important role in the evaluation of patient with brain stem involvement in acute flaccid paralysis.

Key words: Acute flaccid paralysis, Snake eye appearance, Spine MRI (Magnetic Resonance Imaging), Vaccine associated polio virus (VAPP), ADC (Apparent Diffusion Coefficient), PCR (Polymerase Chain Reaction), EMG NCV (electromyography and nerve conduction velocity), OPV (Oral Poliovirus Vaccine).