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    Sunday, April 29, 2007

    Rabies, Still Fatal: Remember the case of the Wisconsin girl who survived rabies? She's still the only one. The technique used for her, unfortunately, has not been successful in others.

    Rabies is often difficult to diagnose, and as these two cases illustrate, sometimes the history of an animal bite is hard to elicit:

    On September 30, 2006, a girl aged 10 years had pain in her right arm, and her parents noticed a skin eruption on her trunk and extremities. On October 3, she began vomiting and had increased arm pain and occasional arm numbness. During her initial visit to her family's primary health-care provider on October 4, radiographs of her arm and clavicle were normal. Three to five days after her initial symptoms began, the patient's speech became difficult to understand, and she had a decreased appetite, sore throat and neck pain, and temperature of 101°F. She became irritable and agitated. A rapid Group A streptococcal antigen test and slide heterophil antibody assay were negative on October 6. The patient was hospitalized on October 7 at a community hospital, where she was found to have difficulty swallowing secretions. Her tongue had a whitish coating and was protruding from her mouth. Her complete blood count and electrolytes were normal. She was prescribed methylprednisolone for possible glossitis and fluconazole for mucosal candidiasis.

    On October 8, neurologic involvement became more evident, and the attending physician arranged for transfer to a university-affiliated tertiary care pediatric hospital. On arrival at the pediatric hospital, the patient was irritable, with intermittent moments of alertness, altered mental status, and lethargy. She had slurred speech and difficulty swallowing secretions and complained of a drowning sensation. Because of difficulty breathing, low oxygen saturation, and excess secretions, the patient was intubated and placed on a mechanical ventilator. .....Vancomycin, cefotaxime, and acyclovir were administered for the presumptive diagnosis of meningoencephalitis. On the second day of hospitalization, the patient experienced episodes of lethargy, somnolence, generalized skin flushing (associated with vancomycin administration), and hypersalivation.

    Initial interviews of family members indicated that the patient frequently was exposed to healthy-appearing household cats and dogs but to no other animals. On the third day of hospitalization, the patient's primary-care physician told staff members at the pediatric hospital that a babysitter suggested the patient might have sustained an animal scratch or bite during June 2006. Family members did not know what type of animal might have scratched her.

    ...The patient's mother reported that in mid-June, the girl had awakened her during the night and said that a bird or bat had flown into her bedroom window and bitten her. The mother saw a small mark on the girl's arm, which the mother washed and treated with an over-the-counter first aid treatment. The mother then went to the girl's bedroom to see whether an animal was present. Finding none, she assumed that the incident was a nightmare, not uncommon for the girl. Approximately 2--3 days later, an older sibling took a dead bat away from the family cat; however, the mother did not associate this event with the previous incident and did not seek rabies PEP for the girl. The mother later reported that at the time of the incident, a bedroom window was probably open without a screen in place.

    The second case involved an even more remote bite:

    On November 15, 2006, a boy aged 11 years had sore throat, fatigue, and fever (101°F). He was taken to his pediatrician's office on November 16 for a previously scheduled childhood vaccination related to his recent immigration from the Philippines on October 2, 2006. He received a diagnosis of pharyngitis and was prescribed amoxicillin; the vaccinations were deferred. That evening, the boy was taken to a hospital emergency department (ED) with chest tightness, dysphagia, and insomnia. He had tachycardia (128 beats/min) and hypertension (148/99 mmHg) but no fever; his respiratory rate and oxygen saturation level were normal.

    During the next several hours in the ED, the boy experienced irregular lip and mouth movements, hallucinations, and agitation. Rabies-associated signs such as aerophobia, hydrophobia, profuse salivation, and copious oral secretions were noted, and he was transported to a tertiary care pediatric hospital. Because the possibility of rabies was raised by providers at the referring hospital, infection-control measures were initiated at the pediatric hospital, including contact and droplet precautions.

    ....The patient's family was asked about possible animal exposures. Although the parents were unaware of any specific incidents, two siblings recalled that the patient had been bitten by a dog approximately 2 years previously, when he was living in the Philippines. He did not receive rabies PEP at that time.

    At CDC, rabies virus RNA was detected by RT-PCR in patient saliva samples obtained on the third hospital day. The gene sequences were similar to those of a canine rabies virus variant from the Philippines.

    Here's more about avoiding rabies, including the recommendations for post-exposure treatment.

    posted by Sydney on 4/29/2007 09:35:00 PM 0 comments


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