Acute Flaccid Myelitis Patient Summary Form

acute flaccid myelitis (AFM) patient summary form

acute flaccid myelitis, AFM, neurologic illness, limb weakness, paralysis

CDC/NCIRD

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PDF patient-summary-form

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: ______________________ -------------------------------------------------------------DETACH and transmit only lower portion to AFMInfo@cdc.gov if sending to CDC-------------------------------------------------------------

Acute Flaccid Myelitis: Patient Summary Form
Please send the following information along with the patient summary form: MRI report MRI images

Form Approved OMB No. 0920-0009 Exp Date: 08/31/2022

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 Native Hawaiian or Other Pacific Islander White (check all that apply)

8. Ethnicity: Hispanic or Latino 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: 15. Weakness? [indicate yes(y), no (n), unknown (u) for each limb]
15a. Tone in affected limb(s) [flaccid, spastic, normal for each limb]

Right Arm

Left Arm

Y N U flaccid spastic normal unknown
Yes No Unk

Y NU flaccid spastic normal unknown

Right Leg
Y NU flaccid spastic normal unknown

Left Leg
Y NU flaccid spastic normal unknown

16. Was patient admitted to ICU?
In the 4-weeks BEFORE onset of limb weakness, did patient:
18. Have a respiratory illness? 20. Have a gastrointestinal illness (e.g., diarrhea or vomiting)? 22. Have a fever, measured by parent or provider 38.0°C/100.4°F? 24. Have pain in neck or back?

17. If yes, admit date: __ __/__ __/__ __ __ __
Yes No Unk
19. If yes, onset date __ __/__ __/__ __ __ __ 21. If yes, onset date __ __/__ __/ __ __ __ __ 23. If yes, onset date __ __/__ __/__ __ __ __ 25. If yes, onset date __ __/__ __/__ __ __ __

26. At onset of limb weakness, does patient have any underlying illnesses?

27. If yes, list:

Magnetic Resonance Imaging:

28. Was MRI of spinal cord performed? yes no unknown 29. If yes, date of spine MRI: __ __/__ __/__ __ __ __

30. Did the spinal MRI show a lesion in at least some spinal cord gray matter? yes no unknown

31. Was MRI of brain performed?

yes no unknown 32. If yes, date of brain MRI: __ __/__ __/__ __ __ __

CSF examination: 33. Was a lumbar puncture performed? yes no unknown If yes, complete 33 (a,b) (If more than 2 CSF examinations, list the first 2 performed)

33a. CSF from LP1 33b. CSF from LP2

Date of lumbar puncture

WBC/mm3 neutrophils lymphocytes monocytes

% eosinophils

Glucose Protein RBC/mm3 mg/dl mg/dl

Public reporting burden of this collection of information is estimated to average 12 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 estima te 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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At time of 60 day follow-up please collect and send the following information: Discharge summary History and physical (H&P) Neurology consult notes EMG report (if done) Infectious disease consult notes (if available) Vaccine registry record Diagnostic laboratory reports
Acute Flaccid Myelitis Outcome follow-up of confirmed and probable AFM cases (completed at 60 days, 6 months and 12 months after onset of limb weakness)
34. Date of follow-up: __ __/__ __/__ __ __ __ (mm/dd/yyyy)
35. Impairment: None Minor (any minor involvement) Significant (2 extremities, major involvement) Severe (3 extremities and respiratory involvement) Death Unknown
35a. Date of death: __ __/__ __/__ __ __ __ (mm/dd/yyyy)
36. Physical condition (includes cardiovascular, gastrointestinal, urologic, endocrine as well as neurologic disorders):
i. Medical problems sufficiently stable that medical or nursing monitoring is not required more often than 3-month intervals ii. Medical or nurse monitoring is needed more often than 3-month intervals but not each week. iii. Medical problems are sufficiently unstable as to require medical and/or nursing attention at least weekly. iv. Medical problems require intensive medical and/or nursing attention at least daily (excluding personal care assistance)
37. Upper limb functions: Self-care activities (drink/feed, dress upper/lower, brace/prosthesis, groom, wash, perineal care) dependent mainly upon upper limb function:
i. Age-appropriate independence in self-care without impairment of upper limbs ii. Age-appropriate independence in self-care with some impairment of upper limbs iii. Dependent upon assistance in self-care with or without impairment of upper limbs. iv. Dependent totally in self-care with marked impairment of upper limbs.
38. Lower limb functions: Mobility (walk, stairs, wheelchair, transfer chair/toilet/tub or shower) dependent mainly upon lower limb function:
i. Independent in mobility without impairment of lower limbs ii. Independent of mobility with some impairment of lower limbs, such as needing ambulatory aids, a brace or prosthesis iii. Dependent upon assistance or supervision in mobility with or without impairment of lower limbs. iv. Dependant totally in mobility with marked impairment of lower limbs.
39. Sensory components: Relating to communication (speech and hearing) and vision:
i. Age-appropriate independence in communication and vision without impairment ii. Age-appropriate independence in communication and vision with some impairment such as mild dysarthria, mild aphasia or need for
eyeglasses or hearing aid. iii. Dependent upon assistance, an interpreter, or supervision in communication or vision iv. Dependent totally in communication or vision
40. Excretory functions (bladder and bowel control, age-appropriate):
i. Complete voluntary control of bladder and bowel sphincters ii. Control of sphincters allows normal social activities despite urgency or need for catheter, appliance, suppositories, etc. iii. Dependent upon assistance in sphincter management iv. Frequent wetting or soiling from bowel or bladder incontinence
41. Support factors:
i. Able to fulfil usual age-appropriate roles and perform customary tasks ii. Must make some modifications in usual age-appropriate roles and performance of customary tasks iii. Dependent upon assistance, supervision, and encouragement from an adult due to any of the above considerations iv. Dependent upon long-term institutional care (chronic hospitalization, residential rehabilitation, etc. Excluding time-limited hospitalization
for specific evaluation or treatment)

Public reporting burden of this collection of information is estimated to average 20 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 estima te 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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Version 7.2 May 12, 2021

Acute Flaccid Myelitis case definition (https://cdn.ymaws.com/www.cste.org/resource/resmgr/ps/positionstatement2020/Interim-20-ID-04_AFM_Final.pdf)
Clinical Criteria An illness with onset of acute flaccid* limb weakness AND Absence of a clear alternative diagnosis attributable to a nationally notifiable condition.
* Low muscle tone, limp, hanging loosely, not spastic or contracted.
Confirmatory laboratory/imaging evidence:
MRI showing spinal cord lesion with predominant gray matter involvement* and spanning one or more vertebral segments, AND Excluding persons with gray matter lesions in the spinal cord resulting from physician diagnosed malignancy, vascular disease, or anatomic abnormalities.
Presumptive laboratory/imaging evidence:
MRI showing spinal cord lesion where gray matter involvement* is present but predominance cannot be determined, AND Excluding persons with gray matter lesions in the spinal cord resulting from physician diagnosed malignancy, vascular disease, or anatomic abnormalities.
Supportive laboratory/imaging evidence:
MRI showing a spinal cord lesion in at least some gray matter* and spanning one or more vertebral segments, AND Excluding persons with gray matter lesions in the spinal cord resulting from physician diagnosed malignancy, vascular disease, or anatomic abnormalities.
* Spinal cord lesions may not be present on initial MRI; a negative or normal MRI performed within the first 72 hours after onset of limb weakness does not rule out AFM. 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 terminology.
Other classification criteria Autopsy findings that include histopathologic evidence of inflammation largely involving the anterior horn of the spinal cord spanning one or more vertebral segments.
Vital Records Criteria Any person whose death certificate lists acute flaccid myelitis as a cause of death or a condition contributing to death.
Case Classification
Confirmed: Meets clinical criteria with confirmatory laboratory/imaging evidence, OR Meets other classification criteria.
Probable: Meets clinical criteria with presumptive laboratory/imaging evidence.
Suspect: Meets clinical criteria with supportive laboratory/imaging evidence, AND Available information is insufficient to classify case as probable or confirmed.
Acute Flaccid Myelitis specimen collection information (https://www.cdc.gov/acute-flaccid-myelitis/hcp/specimen-collection.html)
Acute Flaccid Myelitis job aid (https://www.cdc.gov/acute-flaccid-myelitis/downloads/job-aid-for-clinicians-508.pdf)

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Version 7.2 May 12, 2021

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