A 32 year old right handed nurse received the oral polio vaccine at the same time as her 4 week old daughter because there was some doubt about her previous vaccination history. Ten days later she noticed a heavy aching feeling in her legs, more marked on the right. This started with a stabbing tender sensation in the right hip. She noticed it was difficult to get up from a crouch on the floor and she had difficulty climbing stairs. Her symptoms worsened over 4 weeks and then stabilised. She continued to experience aching in her legs when going upstairs but was able to return to work.

On examination 4 weeks after her first symptom, straight leg raising was 80° bilaterally but with a positive sciatic stretch test on the left. She had difficulty walking heel to toe and rising from a squat. Cranial nerves were normal with no facial weakness. In the limbs there was mild wasting of the right vastus lateralis but no fasciculations. Tone was normal. There was mild proximal weakness of the arms and legs and also some truncal weakness. Coordination was intact. Tendon reflexes were reduced. Sensation was normal.

Routine investigations were normal.

Subsequently, poliovirus DNA was found in the CSF on PCR suggesting a diagnosis of vaccine associated paralytic poliomyelitis (VAPP). A Poliovirus neutralisation test from when she was first seen in clinic confirmed exposure to all three poliovirus subtypes.

She recovered from the acute illness but presented 15 years later with a 6 year history of slow deterioration in her functional capacity. She was aware of fatigue, persistent muscle ache and pain in her arms and legs. Over the 2 years prior to presentation she had become aware of increasing weakness and difficulty getting up from the floor. She was undertaking vigorous exercise in the gym, weight lifting up to three times a week but became increasingly tired and had been unable to sustain this level of exercise.