Case history
Case history #1
An 11-year-old boy presents to the ER with fever, sore throat, and vomiting. The only known animal contacts are house pets. There is no history of travel abroad, but the patient attended a summer camp in Alabama 2 months earlier. The patient has never received rabies immunization. Laboratory tests and CXR are unremarkable and he is sent home. He returns the same day with additional symptoms of insomnia, urinary urgency, paresthesias of the scalp and right arm, dysphagia, disorientation, and ataxia. He deteriorates rapidly, with slurred speech, hallucinations, and agitation requiring sedation and intubation. Tests for West Nile virus, HSV, and enterovirus are negative. The patient progresses to coma over several days, and develops autonomic instability. He dies on the 14th day.
Case history #2
A 52-year-old man, recently arrived from India, presents after 3 days of restlessness and intermittent abdominal pain. Exam shows only diaphoresis and mild distress. He is admitted for possible bowel obstruction. Over 12 hours, he develops cardiac arrhythmia, fever, and increased diaphoresis. He is unable to ingest liquids. The following day he exhibits strange behavior and leg numbness. Later he develops hallucinations, aggressive behavior, hypersalivation, and cardiac arrest. The patient is resuscitated and admitted to the ICU. He has tachycardia, muscular rigidity, and body tremor. An MRI of the brain is unremarkable. A detailed history reveals that the patient had sustained bites from a puppy in India to the right hand and leg 3 months ago and has never received a rabies immunization. At this point rabies is suspected. The patient becomes comatose and dies 2 days later after another cardiac arrest.
Other presentations
Rabies is difficult to diagnose in the absence of identifiable rabies exposure. Clinically, rabies has 2 forms: encephalitic (furious) and paralytic. Both have nonspecific prodromes of fever, chills, malaise, sore throat, vomiting, headaches, and paresthesias. Pain or paresthesias at the site of the animal bite are often present. In the encephalitic form, the prodrome is followed by symptoms of altered mental status, agitation, hyperactivity, tremors, hypersalivation, mydriasis, dysphagia, hydrophobia, and aerophobia. This is followed by paralysis with coma and death. In the paralytic form, there are no early changes in mental status. Ascending weakness appears late in the infection and rapidly progresses to flaccid paralysis, coma, and death. There is the suggestion that milder forms of rabies may exist.[2][3][4] With better access to premortem diagnostics, rare abortive cases, less severe forms, and spontaneous recoveries have been identified.
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