Survival after Treatment of Rabies with Induction of Coma We report the survival of a 15-year-old girl in whom clinical rabies

developed one month after she was bitten by a bat. Treatment included induction of coma while a native immune response matured; rabies vaccine was not administered. The patient was treated with ketamine, midazolam, ribavirin, and amantadine. Probable drug-related toxic effects included hemolysis, pancreatitis, acidosis, and hepatotoxicity. Lumbar puncture after eight days showed an increased level of rabies antibody, and sedation was tapered. Paresis and sensory denervation then resolved. The patient was removed from isolation after 31 days and discharged to her home after 76 days. At nearly five months after her initial hospitalization, she was alert and communicative, but with choreoathetosis, dysarthria, and an unsteady gait. Rabies Exposures, Post-Exposure Prophylaxis and Deaths in a Region of Endemic Canine Rabies Thousands of human deaths from rabies occur annually despite availability of effective vaccines for humans following exposure, and for disease control in domestic dog populations. A 5-year contact-tracing study in northwest Tanzania was established to investigate risk factors associated with rabies exposure and to determine why human deaths from canine rabies still occur. They found that children were at greater risk of being bitten and of developing rabies than adults and that incidence of bites by suspected rabid animals was higher in an area with larger domestic dog populations. A large proportion (>20%) of those bitten by rabid animals are not recorded in official records because they do not seek post-exposure prophylaxis (PEP), which is crucial for preventing the onset of rabies. Of those that seek medical attention, a significant proportion do not receive PEP because of the expense or because of hospital shortages; and victims who are poorer, and who live further from medical facilities, typically experience greater delays before obtaining PEP.

Rabies Crosses the Border The day after entering California from Oaxaca, Mexico, an undocumented 16-year-old male was brought to an emergency department with a sore throat and a recent history of not eating or drinking. He exhibited low-grade fever, tachycardia, agitation, and crying. Discharged after treatment with intravenous fluids, he returned several hours later with the same symptoms plus nausea, vomiting, frequent spitting, and refusal to take oral fluids. Again, he was discharged. The next day, he collapsed at home and could not be resuscitated. Postmortem, rabies was considered, based on the patient's presentation and his emigration from an area with endemic canine rabies. Public health investigation revealed a history of a dog bite and a fox bite in Oaxaca 2 to 3 months before presentation, without subsequent postexposure prophylaxis (PEP). Rabies virus antigen was detected in the patient's brain tissue, and 6 days later, the CDC identified the virus as a variant most closely related to one carried by Mexican free-tailed bats. PEP was given to 20 close contacts (including 4 healthcare workers) exposed to the patient's saliva. Known contacts of the patient have shown no evidence of rabies. New rabies vaccine may require only a single shot, not 6 Almost every 20 minutes a person usually a child dies of rabies. However, a single shot may be all it takes for rabies vaccination than the usual 6 shots. This is according to new research published in the Journal of Infectious Diseases by researchers at the Jefferson Vaccine Center. It is through a live rabies virus which lacks the M gene which is the central gene and is responsible with the budding of the rabies, without it the virus can not complete its life cycle. The virus in the vaccine infects cell but is not able to spread. Also this vaccine is effective for pre exposure and post exposure, and the current standard post-exposure regimen is not feasible in the developing world, where rabies is endemic. Failure of Rabies Postexposure Prophylaxis In Patients Presenting with Unusual Manifestations The patient had rabies despite receiving appropriate treatment. PEP failure cases due to omissions and flaws in PEP have not been rare [610]. Nevertheless, there are reports of human rabies deaths that appeared to be due to true treatment failures. Our patient received proper wound care, vaccination, and HRIG within 6 h after being attacked. Although there were difficulties in infiltrating the wound at the nail bed of the right thumb, a great effort was made by experienced staff to infiltrate this wound with HRIG as recommended. The only deviation from current WHO guidelines was the additional HRIG infiltration of the wounds 4 days after the first treatment. Nevertheless, he was able to mount a good antibody response above the level of 0.5 IU/mL, which is considered adequate for protection from rabies, because his neutralizing antibody level on day 27 was 1.39

IU/mL, as determined using the rapid fluorescent focus inhibition test. The HRIG potency was reassessed and found to be comparable with that of the manufacture's export certiricate (280 vs 150300 IU/mL, respectively). Although some studies suggested that RIG may suppress the antibody production when using the Zagreb (2-1-1 IM) regimen (2 injections on day 0 and 1 each on days 7 and 21), the TRC-ID regimen has been shown not to have any significant suppression of antibody when RIG is administered. The only potential hazard of repeating HRIG infiltration, especially to the wound at the nail bed, may have been trauma to the nerves at the bite site. Although it was possible that the patient might have had exposures other than the one we encountered, our repeated careful detailed history and physical examination did not confirm such a possibility. There have been reports of patients with rabies associated with dog bites who had unusual presentations in Thailand. Some resembled what has been reported in bat-associated cases. The patient described herein presented as paralytic rabies, because classic signs of rabies, such as autonomic dysfunction and phobic spasm, were not obvious; he also had relatively spare consciousness (ie, lesser degree of aggression and agitation). However, initial manifestations were unusual consisting of lockjaw and abnormal eye movements. Lockjaw or trismus is a hallmark of tetanus. Intermittent spasms of the back and neck muscles in this case might be misinterpreted as reflex spasms in tetanus. However, the most important sign of tetanussustained muscular rigidity, especially of the axial musculatureswas missing. Presence of trismus and paralysis of 1 cranial nerve can be a presentation of cephalic tetanus. Abnormal ocular movements, including bilateral trochlear nerve palsy (ophthalmoplegic tetanus) and downbeat nystagmus, have been reported. Nonetheless, oculomotor abnormalities and facial paresis in this case appear to be manifestations of brainstem dysfunction and were unlikely due to tetanus. Our previous neuroimaging studies involving patients with rabies and rabid dogs showed the brainstem as a predilectively involved site. Subsequent development of weakness of limb muscles, starting at both arms where bites were incurred, followed by leg weakness accompanied by loss of deep tendon reflexes excluded tetanus and was the pattern of progression in paralytic rabies. Ascending or descending weakness can be found in paralytic rabies. Miller Fisher syndrome (MFS) and Bickerstaff brainstem encephalitis (BBE), both of which are considered variants of GuillainBarr syndrome, might complicate the diagnosis in this case. Ophthalmoparesis, as described in MFS and BBE, was also found in our case. Weakness of the extremities and areflexia can be found in MFS and BBE. Although profound worsening of consciousness can differentiate rabies from MFS and BBE, this patient died suddenly before any clouding of sensorium developed. This might have been due to autonomic dysfunction (cardiac arrhythmia. Fever after clinical onset plus excessive salivation favored the diagnosis of paralytic rabies The myoedema sign, previously reported in paralytic rabies , was not present, but this was examined before weakness developed. Anti-ganglioside antibodies, as found in Guillain-Barr syndrome, MFS, and BBE, are not present in patients with paralytic rabies. Marked CSF pleocytosis was also unusual.It was not known whether the repeated dose of HRIG might elicit this exaggerated response. Antemortem diagnosis using molecular methods, although sensitive, is not conclusive if the results are negative. Viral shedding is intermittent, and it is essential to repeat the test on as many samples of CSF, saliva, urine, and hair follicles as possible. To date, a total of 50 patients with rabies were tested at our institutions for rabies viral RNA in CSF, saliva, urine, and hair follicles; 3 had tested negative. All 3, including this patient, were cases of paralytic rabies. This case raised the possibility of an unusual strain of rabies or other lyssavirus as cause of the disease. It has been shown that Thai bats also harbored unidentiried lyssavirus(es) on the basis of the presence of cross-neutralizing antibodies against Arawan, Khujand, and Irkut. Spillage of bat viruses might occur to terrestrial animals. Molecular epidemiology surveys of rabies virus from infected animals and humans in Bangkok and from the whole country did not show evidence of other than dog strains.