Fatal case of rabies
CMAJ 1997;156:1311
© 1997 Canadian Medical Association
A recent report[1] of rabies causing the death of a 32-year-old woman in New England prompts us to remind readers of this preventable disease. In the US 2 deaths from rabies occurred in 1996 and 30 cases have been reported since 1980. No cases have been reported in Canada since 1985 (Dr. Paul Varughese, Laboratory Centre for Disease Control, Ottawa: personal communication, 1997). Nearly 3000 people a year receive postexposure prophylaxis (PEP) in Canada because of exposure to animals with rabies or suspected rabies.[2]
The woman had been visiting Nepal during a 6-month trip abroad. She was bitten on the left hand by a stray dog in Kathmandu on June 7, 1996. The wound was washed with peroxide and rubbing alcohol. The dog seemed normal. Because postexposure prophylaxis (PEP) was unavailable locally, the woman sought advice at a hospital in Sydney, Australia, on June 12. Rabies immune globulin (RIG) and rabies vaccine were not immediately available, and she was advised to return the next day. Believing her risk to be low and the benefit of delayed PEP uncertain, she did not return.
On Aug. 12, the patient presented to a hospital in New Hampshire with paresthesias and pain radiating up her left arm. She reported the dog bite but was not given PEP. Anti-inflammatory and analgesic drugs were prescribed.
She returned to hospital 2 days later with progressive dyspnea, severe throat spasms when she attempted to drink, nausea and vomiting. Rabies was suspected and she was transferred to a Massachusetts hospital. Despite aggressive therapy with rabies immune globulin (RIG) and vaccine, the patient died on Aug. 20, 74 days after the bite.
The incubation period for rabies is usually 13 months. Generally, bites closer to the brainstem, such as on the face or arm, result in symptoms more rapidly than bites on the lower extremities. Animal bites should be washed immediately with soap and water. Suturing the wound should be avoided if possible.[2] Physicians should consult the local medical officer of health for advice on the likelihood of rabies, which can vary according to region and the species of animal involved. Rabies virus can be present in the saliva of infected animals 34 days before symptoms appear. If indicated, RIG and rabies vaccine should be given according to the recommended schedule.[2] RIG should not be given to patients who received pre-exposure vaccination, but additional doses of vaccine are required.[2] PEP is effective only if administered before the onset of symptoms and should be given promptly. However, even if a delay occurs, PEP should still be given at any time before symptom onset.
In the US almost half of the cases reported since 1980 resulted from dog bites; of these, almost all were acquired outside the US. The risk is greatest for travellers to areas where canine rabies is endemic, including many parts of Africa, Asia and Central and South America. In many of these countries PEP is unavailable. Moreover, in countries where rabies is rare PEP can be difficult to obtain.
The US Centers for Disease Control and Prevention advise that vaccination be considered for people staying 30 days or more in areas where rabies is endemic and appropriate PEP may be unavailable. Canadian physicians should be alert to the possibility of rabies in returning travellers. -- JH, AMT
References
- Human rabies -- New Hampshire. MMWR 1997;46:267-70.
- Canadian Immunization Guide. 4th ed. Ottawa: Minister of National Health and Welfare; 1993.
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