Far Eastern University – Nicanor Reyes Medical Foundation amplification and sequencing or by characterization with
IM 3A: RABIES monoclonal antibodies.
Dr. Coronel, MD
RABIES
- It is a rapidly progressive, acute infectious disease of the
central nervous system (CNS) in humans and animals that is
caused by infection with rabies virus.
- The infection is normally transmitted from animal vectors
- It has encephalitic and paralytic forms that progress to
death
ETIOLOGIC AGENT
- Rabies virus is a member of the family Rhabdoviridae.
- Two genera in this family contain species that cause human
disease: Lyssavirus and Vesiculovirus
- Rabies virus is a lyssavirus that infects a broad range of
animals and causes serious neurologic disease when
transmitted to humans.
- This single-strand RNA virus has a nonsegmented, negative-
sense (antisense) genome that consists of 11,932
nucleotides and encodes five proteins:
o nucleocapsid protein
o phosphoprotein
o matrix protein
o glycoprotein
o large polymerase protein.
EPIDEMIOLOGY
- Rabies is a zoonotic infection that occurs in a variety of
mammals throughout the world except in Antarctica and on
some islands.
- Usually transmitted to humans by the bite of an infected
animal.
- Canine rabies is endemic in many resource-poor and
resource-limited countries and continues to be a threat to
humans, particularly in Asia and Africa
- Endemic canine rabies has been eliminated from the United
States and most other resource-rich countries.
- It is endemic in wildlife species, and a variety of animal
reservoirs have been identified in different countries
o Domestic animals: Dog, cat, cattle (only 7% of cases
of Rabies)
o Wildlife reservoirs: bats, raccoons, skunk, foxes
- 1/3 of rabies victim are children under 15 years of age
- Dogs remain the principal cause of animal bites and rabies
cases àDOH Philippine data
- "Spillover" of rabies to other wildlife species and to
domestic animals occurs.
- Rabies virus variants isolated from humans or other
mammalian species can be identified by reverse-
transcription polymerase chain reaction (RT---PCR)
INTERNAL MEDICINE 3A: RABIES
- Helpful in human cases with no known history of an
exposure.
- Worldwide, most human rabies is transmitted from dogs in
countries with endemic canine rabies and dog---to---dog
transmission, and human cases can be imported by
travelers returning from these regions.
- Transmission from non-bite exposures is relatively
uncommon.
o Aerosols generated in the laboratory or in caves
containing millions of Brazilian free-tail bats have
rarely caused human rabies.
o Transmission has resulted from corneal
transplantation and recently from solid organ
transplantation and from a vascular conduit (for a
liver transplant) from undiagnosed donors with
rabies.
- Human-to-human transmission is extremely rare, although
theoretical concern about transmission to health care
workers has prompted the implementation of barrier
techniques to prevent exposures.
PATHOGENESIS
- Incubation period (defined as the interval between
exposure and the onset of clinical disease) = 20---90 days;
o rarely as short as a few days or is >1 year.
- During most of the incubation period, rabies virus is
thought to be present at or close to the site of inoculation.
- In muscles, known to bind to nicotinic acetylcholine
receptors on postsynaptic membranes at neuromuscular
junctions
- Rabies virus spreads centripetally along peripheral nerves
toward the CNS at a rate up to 250 mm/d via retrograde
fast axonal transport to the spinal cord or brainstem.
- Once the virus enters the CNS, it rapidly disseminates to
other regions of the CNS via fast axonal transport along
neuroanatomic connections.
- Neurons are prominently infected in rabies; infection of
astrocytes is unusual.
- After CNS infection becomes established, there is
centrifugal spread along sensory and autonomic nerves to
other tissues, including the salivary glands, heart, adrenal
glands, and skin.
- Rabies virus replicates in acinar cells of the salivary glands
and is secreted in the saliva of rabid animals that serve as
vectors of the disease.
- Pathologic studies show mild inflammatory changes in the
CNS in rabies, with mononuclear inflammatory infiltration
in the leptomeninges, perivascular regions, and
parenchyma, including microglial nodules called Babes
nodules.
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 - Degenerative neuronal changes usually are not prominent, - Rabies may be difficult to recognize late in the clinical
and there is little evidence of neuronal death; course when progression to coma has occurred.
neuronophagia is observed occasionally. - A minority of patients present with acute flaccid paralysis.
- The pathologic changes are surprisingly mild in light of the There are prodromal, acute neurologic, and comatose
clinical severity and fatal outcome of the disease. phases that usually progress to death despite aggressive
- The most characteristic pathologic finding in rabies is the therapy
Negri body
o are eosinophilic cytoplasmic
inclusions in brain neurons
that are composed of rabies
virus proteins and viral RNA.
o These inclusions occur in a
minority of infected neurons,
are commonly observed in
Purkinje cells of the
cerebellum and in pyramidal
neurons of the hippocampus,
and are less frequently seen in cortical and
brainstem neurons.
o Negri bodies are not observed in all cases of rabies.
- The lack of prominent degenerative neuronal changes has
CLINICAL STAGES OF RABIES
led to the concept that neuronal dysfunction rather than
neuronal death is responsible for clinical disease in rabies. PRODROMAL FEATURES
- The clinical features begin with nonspecific prodromal
manifestations: fever, malaise, headache, nausea, and
vomiting.
o Anxiety or agitation may also occur.
- The earliest specific neurologic symptoms: paresthesia,
pain, or pruritus near the site of the exposure, which occurs
in 50-80% of patients and strongly suggests rabies.
- The wound has usually healed by this point, and these
symptoms probably reflect infection with associated
inflammatory changes in local dorsal root or cranial sensory
ganglia.

ACUTE NEUROLOGIC DISEASE

- Two acute neurologic forms of rabies are seen in humans:
o Encephalitic (furious): 80%
o Paralytic: 20%

ENCEPHALITIC RABIES
- Common manifestations seen in encephalitic rabies: fever,
confusion, hallucinations, combativeness, and seizures,
may be seen in in other viral encephalitides as well.
- Autonomic dysfunction is common;
o may result in hypersalivation, gooseflesh, cardiac
arrhythmia, and priapism.
CLINICAL MANIFESTATIONS
- Episodes of hyperexcitability are typically followed by
- the emphasis must be on postexposure prophylaxis (PEP)
periods of complete lucidity that become shorter as the
initiated before any symptoms or signs develop.
disease progresses.
- Usually suspected on the basis of the clinical presentation.
- Rabies encephalitis is distinguished by early brainstem
- presents as an atypical encephalitis with relative
involvement, which results in the classic features of:
preservation of consciousness.

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 o Hydrophobia (involuntary, painful contraction of
the diaphragm and accessory respiratory, laryngeal,
and pharyngeal muscles in response to swallowing
liquids)
o Aerophobia (the same features caused by
stimulation from a draft of air).
- These symptoms are probably due to dysfunction of
infected brainstem neurons that normally inhibit
inspiratory neurons near the nucleus ambiguus, resulting
in exaggerated defense reflexes that protect the
respiratory tract.
- The combination of hypersalivation and pharyngeal
dysfunction is also responsible for the classic appearance
of "foaming at the mouth"
- Brainstem dysfunction progresses rapidly, and coma
followed within days by death is the rule unless the course
is prolonged by supportive measures.
- With such measures, late complications can include
o cardiac and/or respiratory failure
o disturbances of water balance (syndrome of
inappropriate antidiuretic hormone secretion or
diabetes insipidus)
o noncardiogenic pulmonary edema, and
o gastrointestinal hemorrhage.
o Cardiac arrhythmias may be due to dysfunction
affecting vital centers in the brainstem or to
myocarditis.
- Multiple-organ failure is common in patients treated
aggressively in critical care units.
PARALYTIC RABIES
- Muscle weakness predominates and cardinal features of
encephalitic rabies (hyperexcitability, hydrophobia, and
aerophobia) are lacking.
- There is early and prominent flaccid muscle weakness,
often beginning in the bitten extremity and spreading to
produce quadriparesis and facial weakness.
- Sphincter involvement is common, sensory involvement is
usually mild, and these cases are commonly misdiagnosed
as Guillain-Barre syndrome.
INTERNAL MEDICINE 3A: RABIES
- Patients with paralytic rabies generally survive a few days
longer than those with encephalitic rabies, but multiple-
organ failure nevertheless ensues.
LABORATORY INVESTIGATIONS
- Most routine laboratory tests yield normal results or show
nonspecific abnormalities.
- Complete blood counts – normal
- Cerebrospinal fluid (CSF): mild mononuclear cell
pleocytosis with a mildly elevated protein level.
o Severe pleocytosis (>1000 white cells/L) is unusual
and should prompt a search for an alternative
diagnosis.
- CT head scans – normal
- MRI brain scans - may show signal abnormalities in the
brainstem or other gray-matter areas, variable and
nonspecific.
- Electroencephalograms - nonspecific abnormalities.
- Important tests in suspected cases of rabies include those
that may identify an alternative, potentially treatable
diagnosis.
DIAGNOSIS
- NOT Considered until late in the clinical course, even with a
typical clinical presentation
- Diagnosis should be considered in patients presenting with
acute atypical encephalitis or acute flaccid paralysis,
including those in whom Guillain-Barre syndrome is
suspected.
- The absence of an animal-bite history is common in North
America.
- The lack of hydrophobia is not unusual in rabies.
- Once rabies is suspected, rabies-specific laboratory tests
should be performed to confirm the diagnosis.
- Diagnostically useful specimens: serum, CSF, fresh saliva,
skin biopsy samples from the neck, and brain tissue (rarely
obtained before death).
- Skin biopsy: demonstration of rabies virus antigen in
cutaneous nerves at the base of hair follicles, samples are
usually taken from hairy skin at the nape of the neck.
- Corneal impression smears - low diagnostic yield; not
performed.
- Negative antemortem rabies - specific laboratory tests
never exclude a diagnosis of rabies, and tests may need to
be repeated after an interval for diagnostic confirmation.
RABIES VIRUS SPECIFIC ANTIBODIES
- In a previously unimmunized patient, serum-neutralizing
antibodies to rabies virus are diagnostic
- Rabies virus infects immunologically privileged neuronal
tissues;
o serum antibodies may not develop until late in the
disease.
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 - Antibodies may be detected within a few days after the
onset of symptoms, but some die without detectable
antibodies.
- Presence of rabies virus specific antibodies in the CSF
suggests rabies encephalitis, regardless of immunization
status.
RT-PCR AMPLIFICATION
- Detection of rabies virus RNA by RT-PCR is highly sensitive
and specific.
- Can detect virus in: fresh saliva, CSF, and skin and brain
tissues.
- RT-PCR with genetic sequencing can distinguish among
rabies virus variants, permitting identification of the
probable source of an infection.
DIRECT FLUORESCENT ANTIBODY (DFA) TESTING
- DFA testing with rabies virus antibodies conjugated to
fluorescent dyes is highly sensitive and specific and can be
performed quickly and applied to skin biopsies and brain
tissue.
- In skin biopsies, rabies virus antigen may be detected in
cutaneous nerves at the base of hair follicles.
GOLD STANDARD – CDC
- IMMUNOHISTOCHEMISTRY
o sensitive and specific means to detect rabies in
formalin---fixed tissues
- ELECTRON MICROSCOPY
o ultrastructure of viruses
o bullet---shaped particles
- AMPLIFICATION METHODS
o Mouse neuroblastoma cells (MNA) and baby
hamster kidney (BHK) cells
o Biochemical methods
DIFFERENTIAL DIAGNOSIS
- Difficult without a history of animal exposure, and no
exposure to an animal may be recalled. (e.g. bat)
- The presentation of rabies is usually quite different from
that of acute viral encephalitis due to most other causes,
including herpes simplex encephalitis and arboviral (e.g.,
West Nile) encephalitis.
- Early neurologic symptoms may occur at the site of the
bite, and there may be early features of brainstem
involvement with preservation of consciousness.
- Post-infectious (immune-mediated) encephalomyelitis may
follow influenza, measles, mumps, and other infections;
o it may also occur as a sequela of immunization with
rabies vaccine derived from neural tissues, which
are used only in resource-limited and resource-poor
countries.
- Rabies may present with unusual neuropsychiatric
symptoms and may be misdiagnosed as a psychiatric
INTERNAL MEDICINE 3A: RABIES
disorder. Rabies hysteria may occur as a psychological
response to the fear of rabies and is often characterized
by a shorter incubation period than rabies, aggressive
behavior, inability to communicate, and a long course
with recovery.
- Paralytic rabies may mimic Guillain-Barre syndrome.
o In these cases, fever, bladder dysfunction, a normal
sensory examination, and CSF pleocytosis favor a
diagnosis of rabies.
o Conversely, Guillain-Bare may occur as a
complication of rabies vaccination with a neural
tissue-derived product (e.g., suckling mouse brain
vaccine) and may be mistaken for paralytic rabies
(i.e., vaccine failure).
TREATMENT
- No established treatment for rabies.
- Recent treatment failures with the combination of antiviral
drugs, ketamine, and therapeutic (induced) coma measures
that were used in a healthy survivor in whom antibodies to
rabies virus were detected at presentation.
- A palliative approach may be appropriate for some
patients.
PROGNOSIS
- Rabies is an almost uniformly fatal disease but is almost
always preventable with appropriate post-exposure
therapy during the early incubation period.
- There are seven well-documented cases of survival from
rabies.
o 6 had received rabies vaccine before disease onset.
1 survivor who had not received vaccine had
neutralizing antibodies to rabies virus in serum and
CSF at clinical presentation.
- Most patients with rabies die within several days of illness,
despite aggressive care in a critical care unit.
PREVENTION
POSTEXPOSURE PROPHYLAXIS
- Since there is no effective therapy for rabies, it is extremely
important to prevent the disease after an animal exposure.
- On the basis of the history of the exposure and local
epidemiologic information, the physician must decide
whether initiation of PEP is warranted.
- Healthy dogs, cats, or ferrets may be confined and
observed for 10 days - PEP is not necessary if the animal
remains healthy.
- If the animal develops signs of rabies during the
observation period, it should be euthanized immediately,
and the head should be transported to the laboratory
under refrigeration and examined by DFA testing and viral
isolation using cell culture and/or mouse inoculation.
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 - Any animal other than a dog, cat, or ferret should be
euthanized immediately and the head submitted for
laboratory examination.
- In high-risk exposures and in areas where canine rabies is
endemic, rabies prophylaxis should be initiated without
waiting for laboratory results.
- If the laboratory results prove to be negative, may safely
be concluded that the animal's saliva did not contain
rabies virus, and immunization should be discontinued.
- If an animal escapes after an exposure, it must be
considered rabid, and PEP must be initiated unless
information from public health officials indicates
otherwise (i.e., there is no endemic rabies in the area).
- PEP may be warranted in situations where a person (e.g., a
small child or a sleeping adult) is present in the same space
as a bat and an unrecognized bite cannot be reliably
excluded.
- PEP includes local wound care and both active and passive
immunization.
- Local wound care is essential and may greatly decrease the
risk of rabies virus infection.
- Wound care should not be delayed, even if the initiation of
immunization is postponed pending the results of the 10--
day observation period.
INTERNAL MEDICINE 3A: RABIES
- All bite wounds and scratches should be washed
thoroughly with soap and water.
- Devitalized tissues should be debrided, tetanus prophylaxis
given, and antibiotic treatment initiated whenever
indicated.
- All previously unvaccinated persons (but not those who
have previously been immunized) should be passively
immunized with rabies immune globulin (RIG).
- If RIG is not immediately available, it should be
administered no later than 7 days after the first vaccine
dose.
- After day 7, endogenous antibodies are being produced,
and passive immunization may actually be
counterproductive.
- If anatomically feasible, the entire dose of RIG (20 IU/kg)
should be infiltrated at the site of the bite; otherwise, any
RIG remaining after infiltration of the bite site should be
administered IM at a distant site.
- With multiple or large wounds, the RIG preparation may
need to be diluted in order to obtain a sufficient volume for
adequate infiltration of all wound sites.
- If the exposure involves a mucous membrane, the entire
dose should be administered IM.
- Rabies vaccine and RIG should never be administered at
the same site or with the same syringe.
- Commercially available RIG in U.S. is purified from the
serum of hyperimmunized human donors.
o are much better tolerated than are the equine-
derived preparations still in use in some countries;
o Serious adverse effects of human RIG are
uncommon.
o Local pain and low-grade fever may occur.
- Two purified inactivated rabies vaccines are available for
rabies PEP in the U.S.
o are highly immunogenic and remarkably safe
compared with earlier vaccines.
- Four 1-mL doses of rabies vaccine should be given IM in the
deltoid area. (The anterolateral aspect of the thigh is also
acceptable in children.)
- Gluteal injections, which may not always reach muscle,
should not be given -rare vaccine failures.
- Ideally, the first dose should be given ASAP after exposure;
should be given without further delay.
- The 3 additional doses should be given on days 3, 7, and 14;
- Fifth dose on day 28 is no longer recommended.
- Pregnancy is not a contraindication for immunization.
- Glucocorticoids and other immunosuppressive medications
may interfere with the development of active immunity
and should not be administered during PEP unless they are
essential.
- Routine measurement of serum neutralizing antibody titers
is not required, but titers should be measured 2-4 weeks
after immunization in immunocompromised persons.
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 - Local reactions (pain, erythema, edema, and pruritus) and
mild systemic reactions (fever, myalgias, headache, and
nausea) are common; anti-inflammatory and antipyretic
medications may be used, but immunization should not be
discontinued.
- Systemic allergic reactions are uncommon, but anaphylaxis
does occur rarely and can be treated with epinephrine and
antihistamines.
- Before discontinuation, weigh the risk of development of
rabies.
PREEXPOSURE RABIES VACCINATION
- Pre-exposure rabies prophylaxis - considered for people
with an occupational or recreational risk of rabies
exposures, including certain travelers to rabies---endemic
areas.
- Primary schedule consists of three doses of rabies vaccine
given on days 0, 7, and 21 or 28.
- Serum neutralizing antibody tests help determine the need
for subsequent booster doses.
- When a previously immunized individual is exposed to
rabies, two booster doses of vaccine should be
administered on days 0 and 3.
- Wound care remains essential.
- RIG should not be administered to previously vaccinated
persons.
GLOBAL CONSIDERATIONS (from Yang Trans)
- Worldwide, endemic canine rabies is estimated to cause
55,000 human deaths annually. Most of these deaths occur
in Asia and Africa, with rural populations and children most
frequently affected.
- Vaccines grown in either primary cell lines (hamster or dog
kidney) or continuous cell lines (Vero cells) are satisfactory
and are available in many countries.
- Less expensive vaccines derived from neural tissues have
been used in developing countries --- associated with
serious neuroparalytic complications, including
postinfectious encephalomyelitis and Guillain---Barre
syndrome.
- The use of these vaccines should be discontinued as soon
as possible, and progress has been made in this regard.
- Worldwide, >10 million individuals receive postexposure
vaccination against rabies each year.
- If human RIG is unavailable, purified equine RIG can be used
in the same manner at a dose of 40 IU/kg. Before the
administration of equine RIG, hypersensitivity should be
assessed by intradermal testing with a 1:10 dilution. The
incidence of anaphylactic reactions and serum sickness has
been low with recent equine RIG products.
INTERNAL MEDICINE 3A: RABIES
OTHER RHABDOVIRUSES
OTHER LYSSAVIRUSES
- A growing number of lyssaviruses other than rabies virus
have been discovered to infect bat populations in Africa,
Europe, and Australia.
- Four of these viruses have produced a very small number
of cases of a human disease indistinguishable from rabies:
o European bat lyssaviruses 1 and 2
o Australian bat lyssavirus
o Duvenhage virus (in Africa)
- Mokola virus, a lyssavirus that has been isolated from
shrews with an unknown reservoir species in Africa, may
also produce human disease indistinguishable from rabies.
VESICULAR STOMATITIS VIRUS (VSV)
- Viral disease of cattle, horses, pigs, and some wild
mammals.
- VSV is a member of the genus Vesiculovirus in the family
Rhabdoviridae.
- Outbreaks of vesicular stomatitis in horses and cattle occur
sporadically in the southwestern United States. The animal
infection is associated with severe vesiculation and
ulceration of oral tissues, teats, and feet and may be
clinically indistinguishable from the more dangerous foot-
-and-mouth disease.
- Epidemics are usually seasonal, typically beginning in the
late spring, and are probably due to arthropod vectors.
- Direct animal-to-animal spread can also occur, although the
virus cannot penetrate intact skin.
- Transmission to humans usually results from direct contact
with infected animals (particularly cattle) and occasionally
follows laboratory exposure. In human disease, early
conjunctivitis is followed by an acute influenza-like illness
o with fever, chills, nausea, vomiting, headache,
retrobulbar pain, myalgias, substernal pain,
malaise, pharyngitis, and lymphadenitis.
- Small vesicular lesions may be present on the buccal
mucosa or on the fingers. Encephalitis is very rare.
- The illness usually lasts 3-6 days, with complete recovery.
- Subclinical infections are common.
- A serologic diagnosis can be made on the basis of a rise in
titer of complement-fixing or neutralizing antibodies.
- Therapy is symptom-based.
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 CATEGORY AND MANAGEMENT OF RABIES – CDC, FROM YANG
TRANS
INTERNAL MEDICINE 3A: RABIES
ADMINISTRATION (from Yang Trans)
- RIG should not exceed the computed dose as it may reduce the
efficacy of the vaccine. If the computed dose is insufficient to
infiltrate all bite wounds, it may be diluted with sterile saline 2
or 3 fold for thorough infiltration of all wounds.
- RIG should be administered at the same time as the first dose
of vaccine (day 0). In case RIG is unavailable on day 0, it may
still be given any time before the day 7 dose of the vaccine.
However if the day 3 and/or day 7 doses of the vaccine have
not been given, RIG may still be given anytime.
- In the event that RIG and vaccine cannot be given on the same
day, the vaccine should be given before RIG because the latter
inhibits the level of neutralizing antibodies induced by
immunization.
- RIG is given only once during the same course of PEP.
- Patients with Positive skin test to purified ERIG should be given
HRIG.
- HRIG is preferred for the following:
o History of hypersensitivity to equine sera
o Multiple severe exposures (especially where dog is sick
or suspected of being rabid) on head and neck area
o Symptomatic HIV infected patients
- Patient must be observed for at least one hour after
USE AT YOUR OWN RISK! NO PROOFREADING WAS DONE!
Notes mostly from Harrisons (BOOK BASED), and Yang Trans
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