Fatal rabies despite post-exposure prophylaxis: a case repor
The following case has been reported in the Indian Journal of Medical Microbiology.

A 3-year-old child had dog bite on right thigh on 6 th January 2009. There was a single bite mark in the form of lacerated wound of size 2 cm × 2.5 cm (category III). The dog was a stray dog of the same locality and had symptoms of rabies. It was killed by people on the next day.

The child received four doses of purified chick embryo cell-derived antirabies vaccine on 7 th , 12 th , 17 th and 20 th January, 2009. The next dose of vaccine was due on 5 th February 2009. He did not receive antirabies serum. The child remained asymptomatic till 24 th January, 2009. On 25 th January, 2009, he developed fever, pain and weakness over the right lower limb. On the same day, he was referred to a tertiary care hospital.

On admission, the patient was febrile and drowsy and vital signs were stable. There was no sign of neck rigidity, no cerebral signs and the ophthalmic examination was within normal limits.

Cerebrospinal fluid (CSF) examination revealed slightly increased protein, 110 mg% (normal range, 15-45 mg%). CSF sugar was 80 mg%, which was within the normal range.

The weakness initially involving the right lower limb progressed to involve the left lower limb, followed by the upper limbs over the next 2 days. Finally, he developed quadriplegia. However, the classical symptoms of rabies, i.e. hydrophobia and aerophobia, were not present any time during his illness.

On 27 th January, 2009 the patient developed respiratory paralysis. The patient was intubated and cardiopulmonary resuscitation was given. However, the patient died at 2 am on 28 th January, 2009. Provisional diagnosis of rabies encephalitis was made even though classical symptoms of rabies, such as aerophobia and hydrophobia, were not present. The possibility of vaccine-induced acute disseminated encephalomyelitis, although rare with the modern cell culture vaccine, was also considered. To confirm the diagnosis, an autopsy was performed giving more attention to the brain.

On gross examination, the brain was mildly congested. Eight impression smears from the hippocampus of the brain were taken and four were stained with Sellers stain. Intracytoplasmic inclusion bodies indicative of Negri bodies were detected by microscopic examination.

Half of the brain was collected in 50% glycerol-saline for further confirmation. Direct immunofluorecence test was performed on the remaining impression smears. Reverse transcriptase polymerase chain reaction was performed on the collected brain tissue, which confirmed the diagnosis of rabies.

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D●●●●●●●u R●●●●●●●●●●n and 9 others like this9 shares
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Dr. G K●●●r
Dr. G K●●●r General Medicine
As per WHO guidelines, Rabies immunoglobulin along with vaccine has to be administered for each and every encounter with dog(bite/scratch) which results in bleeding. Most of the dog bite cases which present to the clinician are gr.3 bites.Considering the prohibitive cost of RIG, is it practical to use in each and every case of dog bite/scratch with bleed?
Oct 22, 2018Like3
Dr. R●●●●●●a A●N
Dr. R●●●●●●a A●N Paediatrics
In this case post exposure prophylaxis is not followed as per schedule strictly on DAY 0 3 7 14 28 and Human RIG or Rabi shield 0.33mg per kg simultaneously would have saved the child. This boy has received PET incorrectly. Dr. A.N.Rajendra. member APCRI
Oct 25, 2018Like6
Dr. N●●. S●●h
Dr. N●●. S●●h Pathology
I agree with Dr Rajendra .All the grade three dog bite cases of stray dog specially should be given anti rabies serum around wound and intramuscular in deep gluteal region .Deeper the would specially lacerated spread faster.
Oct 30, 2018Like