Unprotected People Rabies

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					Unprotected People #71
Wisconsin Teen Survives Clinical Rabies Without Pre- or
Postexposure Prophylaxis

Bitten by a bat in September 2004, a 15-year-old             infected animal, and is nearly always fatal without
Wisconsin girl was hospitalized in October.                  proper postexposure prophylaxis (PEP). In October
Subsequently, the patient’s bat-bite history was             2004, a previously healthy female aged 15 years in
reported, and rabies was diagnosed. Clinical                 Fond du Lac County, Wisconsin, received a
management included intubation, drug-induced coma,           diagnosis of rabies after being bitten by a bat
ventilator support, and intravenous administration of        approximately 1 month before symptom onset. This
ribavirin. The patient survived, making her the only         report summarizes the investigation conducted by
person documented to have recovered from clinically          the Wisconsin Division of Public Health (WDPH),
diagnosed rabies without pre- or postexposure                the public health response in Fond du Lac County,
prophylaxis. As of December 17, the patient remained         and the patient’s clinical course through December
hospitalized, undergoing rehabilitation. Prognosis for       17. This is the first documented recovery from
her full recovery was unknown.                               clinical rabies by a patient who had not received
                                                             either pre-or postexposure prophylaxis for rabies.
Though the patient survived, no proven therapy for
clinical rabies has been established, and the reasons        While attending a church service in September, the
for recovery in this case are unknown. It remains            girl picked up a bat after she saw it fall to the floor.
important for clinicians and the public to be aware          She released the bat outside the building; it was not
of the risk of contracting rabies from direct contact        captured for rabies testing, and no one else touched
with bats and other wildlife and to follow the steps         the bat. While handling the bat, she was bitten on
outlined in the concluding paragraph of the report           her left index finger. The wound was approximately
reprinted below.                                             5 mm in length with some blood present at the
                                                             margins; it was cleaned with hydrogen peroxide.
Titled “Recovery of a Patient from Clinical Rabies—
                                                             Medical attention was not sought, and rabies PEP
Wisconsin, 2004,” the report initially appeared in
                                                             was not administered.
MMWR on December 24, 2004. It was reported by
the following from Wisconsin: RE Willoughby, MD, and         Approximately 1 month after the bat bite, the girl
MM Rotar of Children’s Hospital of Wisconsin,                complained of fatigue and tingling and numbness of
Milwaukee; HL Dhonau, MD, and KM Ericksen of                 the left hand. These symptoms persisted, and 2 days
Agnesian HealthCare, Fond du Lac; DL Cappozzo of             later she felt unsteady and developed diplopia (i.e.,
Fond du Lac County Health Dept.; JJ Kazmierczak,             double vision). On the third day of illness, with
DVM, and JP Davis, MD, of Wisconsin Div. of Public           continued diplopia and onset of nausea and
Health. Contributors from CDC include CE Rupprecht,          vomiting, she was examined by her pediatrician
VMD, of Div. of Viral and Rickettsial Diseases; AP           and referred to a neurologist. At that time, the
Newman, DVM, and AS Chapman, DVM, Epidemic                   patient continued to have blurred vision and also
Intelligence Service officers.                               had partial bilateral sixth-nerve palsy. Magnetic
                                                             resonance imaging (MRI) with and without contrast
Recovery of a Patient from Clinical Rabies—                  and magnetic resonance angiography (MRA) studies
Wisconsin, 2004                                              of her brain were normal, and the patient was
Rabies is a viral infection of the central nervous           sent home.
system, usually contracted from the bite of an                                                        (continued on next page)

                                                • Item #T2011-71 (12/30/04)

Immunization Action Coalition • St. Paul, MN 55104 • (651) 647-9009 • •
Unprotected People #71: Wisconsin Teen Survives Clinical R abies Without Pre- or Postexposure Prophylaxis
            People      Wisconsin Teen                   Rabies Without Pre- Postexposure Prophylaxis

On the fourth day of illness, the patient’s symptoms              Clinical management of the patient consisted of
continued, and she was admitted to a local hospital               supportive care and neuroprotective measures,
for lumbar puncture and supportive care. On                       including a drug-induced coma and ventilator
admission, she was afebrile, alert, and able to follow            support. Intravenous ribavirin was used under an
commands. She had partial sixth-nerve palsy, blurred              investigational protocol. The patient was kept
vision, and unsteady gait. Standard precautions for               comatose for 7 days; during that period, results from
infection control were observed. Lumbar puncture                  lumbar puncture indicated an increase in antirabies
revealed a white blood cell count of 23 cells/                    IgG [immunoglobulin G] by immunofluorescent
microliter (normal: 0 cells/microliter) with 93%                  assay from 1:32 to 1:2,048. Her coma medications
lymphocytes, a red blood cell count of 3 cells/                   were tapered, and the patient became increasingly
microliter (normal: 0 cells/microliter), a protein                alert. On the 33rd day of illness, she was extubated;
concentration of 50 mg/dL (normal: 15-45 mg/dL),                  3 days later she was transferred to a rehabilitation
and a glucose concentration of 58 mg/dL (normal:                  unit. At the time of transfer, she was unable to speak
40-70 mg/dL). During the next 36 hours, she had                   after prolonged intubation. As of December 17, the
slurred speech, nystagmus, tremors of the left arm,               patient remained hospitalized with steady
increased lethargy, and a temperature of 102                      improvement. She was able to walk with assistance,
degrees F (38.9 degrees C).                                       ride a stationary cycle for 8 minutes, and feed herself
                                                                  a soft, solid diet. She solved math puzzles, used sign
On the sixth day of illness, the bat-bite history was
                                                                  language, and was regaining the ability to speak. The
reported, and rabies was considered in the
                                                                  prognosis for her full recovery is unknown.
differential diagnosis. The patient was transferred
to a tertiary-care hospital. Because rabies was                   To provide community members accurate
recognized as a possibility, expanded infection-                  information about rabies and its transmission, local
control measures, including droplet precautions                   and state health officials held a press conference on
and one-to-one nursing, were instituted at time                   October 21. Public health officials and community
of transport. On arrival, the patient had a                       pediatricians visited the patient’s school to assess the
temperature of 100.9 degrees F (38.3 degrees C),                  need for rabies prophylaxis among students. WDPH
impaired muscular coordination, difficulty speaking,              distributed assessment tools to the local health
double vision, muscular twitching, and tremors in                 department to screen healthcare workers and
the left arm. She was somewhat obtunded but                       community contacts of the patient for exposure to
answered questions appropriately and complied                     potentially infectious secretions. The patient’s five
with commands.                                                    family members, five of 35 healthcare workers, and
                                                                  27 of 55 community contacts received rabies PEP      ,
Blood serum, cerebrospinal fluid (CSF), nuchal skin
                                                                  either because of exposure to the patient’s saliva
samples, and saliva were submitted to CDC for
                                                                  during sharing of beverages or food items or after
rabies testing. MRI with and without contrast and
                                                                  contact with vomitus. No healthcare workers at the
angiogram/venogram sequences were normal. She
                                                                  tertiary-care hospital required PEP Site inspection of
had hypersalivation and was intubated. Rabies-virus-
                                                                  the church revealed no ongoing risk for exposure
specific antibodies were detected in the patient’s
                                                                  to bats.
serum and CSF. Direct fluorescent antibody staining
of nuchal skin biopsies was negative for viral antigen,
                                                                  Editorial Note
and rabies virus was not isolated from saliva by cell
                                                                  This case represents the sixth known occurrence of
culture. Rabies-virus RNA was not detectable by
                                                                  human recovery after rabies infection; however, the
reverse transcriptase polymerase chain reaction
                                                                  case is unique because the patient received no
assay of either sample. Therefore, identification of
                                                                  rabies prophylaxis either before or after illness
the virus variant responsible for this infection was
                                                                  onset. Historically, the mortality rate among
not possible.
                                                                                                            (continued on next page)

Immunization Action Coalition • St. Paul, MN 55104 • (651) 647-9009 • •
Unprotected People #71: Wisconsin Teen Survives Clinical R abies Without Pre- or Postexposure Prophylaxis
            People      Wisconsin Teen                   Rabies Without Pre- Postexposure Prophylaxis

previously unvaccinated rabies patients has been                  contaminated by infectious material (e.g., saliva,
100%. The five previous patients who survived                     tears, CSF, or neurologic tissue). Adherence to
were either previously vaccinated or received some                standard precautions for infection control will
form of PEP before the onset of illness. As in this               minimize the risk for exposure.
case, viral antigen was not detected nor was virus
                                                                  Rabies in humans is preventable with proper wound
isolated from those patients; increased antibody
                                                                  care and timely and appropriate administration of
titers detected in serum and CSF (inconsistent with
                                                                  PEP before onset of clinical disease. PEP is
vaccination alone) confirmed the diagnosis of clinical
                                                                  recommended for all persons with a bite, scratch, or
rabies. Only one of the five patients recovered
                                                                  mucous-membrane exposure to a bat, unless the
without neurologic sequelae. No specific course of
                                                                  bat tests negative for rabies. When direct contact
treatment for rabies in humans has been
                                                                  between a human and a bat has occurred and the
demonstrated to be effective, but a combination of
                                                                  animal is not available for testing, PEP should be
treatments, which might include rabies vaccine,
                                                                  administered when a strong probability of exposure
rabies immune globulin, monoclonal antibodies,
                                                                  exists. However, if a bat bite is unrecognized or if
ribavirin, interferon-alpha, or ketamine, has been
                                                                  the significance of exposure is underestimated,
proposed. Given the lack of therapeutic utility
                                                                  medical intervention might not be sought and
observed to date, and because the patient had
                                                                  appropriate treatment not administered. Once
rabies-virus-neutralizing antibodies on diagnosis, a
                                                                  clinical signs of rabies are evident, a progressive and
decision was made to avoid use of immune-
                                                                  usually fatal encephalitis ensues.
modulators (e.g., rabies vaccine, rabies immune
globulin, or interferon). However, the particular                 This report underscores the need for increasing
benefits of the regimen received by this patient                  public awareness to minimize the risk for rabies
remain to be determined.                                          following contact with bats and other wildlife.
                                                                  Persons bitten by a potentially rabid animal should
The history of a bat bite 1 month before this
                                                                  immediately (1) wash the wound thoroughly with
patient’s illness suggests an etiology of bat-associated
                                                                  soap and water, (2) capture the animal (if this can be
rabies-virus variant. This is consistent with the
                                                                  done safely by avoiding direct contact) and submit it
epidemiologic pattern of rabies in humans in the
                                                                  for testing or quarantine, (3) contact local or state
United States during the preceding 2 decades.
                                                                  public health officials, and (4) visit a physician for
During 1980-2000, a total of 26 (74%) of rabies-
                                                                  treatment and evaluation regarding the need for PEP    .
virus variants obtained from patients in the United
                                                                  Persons should not handle or keep bats as pets and
States were associated with insectivorous bats, most
                                                                  should keep bats away from living quarters and
commonly silver-haired and eastern pipistrelle bats,
                                                                  public places. Despite the recovery of this patient,
including a variant from a fatal case of rabies
                                                                  no proven therapy for clinical rabies has been
reported in Wisconsin in 2000.
                                                                  established, and the reasons for recovery in this case
In this case, only five healthcare workers received               are unknown. Clinicians and the public should
PEP Previous reports of rabies cases have noted                   recognize the risk for contracting rabies from any
large numbers of contacts being treated; however,                 direct contact with bats and not regard it as a
delivery of health care to a patient with rabies is not           curable disease on the basis of the outcome of
an indication for PEP unless the mucous membranes                 this case.
or open wound of a healthcare worker are

Immunization Action Coalition • St. Paul, MN 55104 • (651) 647-9009 • •

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