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Rabies detected in Virginia man
CDC. MMWR. 2010;58:1236-1238.
The CDC reported today on the seventh case since 2000 of imported rabies in a 42-year-old man from Virginia.
The man died after 25 days in the hospital.
The patient had reported an encounter with a dog while in India approximately 3 months before the onset of symptoms, according to family contacts. On Oct. 23, 2009, the man reported chills and hot flashes.
During the next several days, the patient visited the ED and a primary care physician with a variety of symptoms progressing from leg discomfort, spontaneous ejaculation, urinary incontinence and back pain radiating to the left lower extremity to anxiety, erratic behavior and involuntary dystonic movements of the upper extremities.
An initial diagnosis with magnetic resonance imaging was of lumbar back pain, and a later computed tomography scan indicated left maxillary sinusitis.
Upon deterioration of symptoms and further analysis, the patient was admitted to the hospital with a differential diagnosis that included rabies and other neurologic diagnoses of unknown etiology, according to results. Clinicians initiated empiric antimicrobial and antiviral therapy for meningoencephalitis.
Early in his hospital stay, the patient’s tachycardia and hypertension worsened, and he was transferred to the ICU, at which point seizures and sustained cardiac arrest culminated with the patient being placed on ventilator support. The patient had low-grade fever. Blood analysis results indicated mild leukocytosis, mild hyperglycemia and a creatine kinase of more than 16,000 U/mL. Large blood and hyaline casts were detected during urinalysis.
On the second day in the hospital, the treating physician initiated the Milwaukee protocol, including ketamine infusion. The patient was not given rabies immune globulin, vaccine or antivirals; however, serum, cerebrospinal fluid, nuchal skin biopsy and saliva were collected and submitted to CDC for rabies testing.
After increasing episodes of asystole, the patient developed inappropriate antidiuretic hormone secretion, followed by severe central diabetes insipidus treated with desmopressin and continuous vasopressin infusion, according to the findings. The patient later developed late and marginal antibody response in saliva, but neutralizing antibodies never developed in the cerebrospinal fluid.
After a week of tapered sedation, brain stem reflexes were lost and autonomic dysfunction diminished.
The Virginia Department of Health and the Fairfax County Health Department collaborated with hospital staff to generate a list of 174 possible contacts. Thirty-two individuals (18%) initiated pre-exposure prophylaxis.
CDC researchers encouraged further awareness of the risk for rabies when traveling to countries where the disease is endemic and stressed the importance of prophylaxis after potential exposure.
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