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Rabies is a viral encephalitis transmitted by the saliva of infected bats and certain other infected mammals. Symptoms include depression and fever, followed by agitation, excessive salivation, and hydrophobia. Diagnosis is by serologic tests or biopsy. Vaccination is indicated for people at high risk of exposure. Postexposure prophylaxis involves wound care and passive and active immunoprophylaxis and, if promptly and meticulously executed, almost always prevents human rabies. Otherwise, the disorder is almost universally fatal. Treatment is supportive.
Rabies causes > 55,000 human deaths worldwide annually, mostly in Latin America, Africa, and Asia, where canine rabies is endemic. In the US, vaccination of domestic animals has reduced rabies cases in people to < 3/yr, mostly transmitted by infected bats. Infected raccoons, skunks, and foxes can also transmit rabies.
Rabid animals transmit the infection through their saliva, usually by biting. Rarely, the virus can enter through a skin abrasion or across mucous membranes of the eyes, nose, or mouth. The virus travels from the site of entry via peripheral nerves to the spinal cord (or to the brain stem when the face is bitten), then to the brain. It then spreads from the CNS via peripheral nerves to other parts of the body. Involvement of the salivary glands and oral mucosa is responsible for transmissibility.
Pain or paresthesias may develop at the site of the bite. Rapidity of progression depends on the viral inoculum and proximity of the wound to the brain. The incubation period averages 1 to 2 mo but may be > 1 yr.
Initial symptoms are nonspecific: fever, headache, and malaise. Within days, encephalitis (furious rabies; in 80%) or paralysis (dumb rabies; in 20%) develops. Encephalitis causes restlessness, confusion, agitation, bizarre behavior, hallucinations, and insomnia. Salivation is excessive, and attempts to drink cause painful spasms of the laryngeal and pharyngeal muscles (hydrophobia). In the paralytic form, ascending paralysis and quadriplegia develop without delirium and hydrophobia.
Rabies is suspected in patients with encephalitis or ascending paralysis and a history of an animal bite or exposure to bats; bat bites may be superficial and overlooked.
Direct fluorescence antibody testing of a biopsy specimen of skin from the nape of the neck is the diagnostic test of choice. Diagnosis can also be made by PCR of CSF, saliva, or tissue. Specimens tested for rabies antibodies include serum and CSF. CT, MRI, and EEG are normal or show nonspecific changes.
Treatment is only supportive and includes heavy sedation (eg, with ketamine and midazolam) and comfort measures. Death usually occurs 3 to 10 days after symptoms begin. Few patients have survived; many received immunoprophylaxis before onset of symptoms. There is evidence that giving rabies vaccine and immune globulin after clinical rabies develops may cause more rapid deterioration.
Experimental therapies with ribavirin, amantadine, interferon-alfa, and other drugs are sometimes tried in desperation (see Care of Rabies protocol ).
Rabid animals can often be recognized by their strange behavior; they may be agitated and vicious, weak, or paralyzed and may show no fear of people. Nocturnal animals (eg, bats, skunks, raccoons) may be out during the day. Bats may make unusual noises and have difficulty flying. An animal suspected of having rabies should not be approached. Local health authorities should be contacted to remove the animal.
Human diploid cell rabies vaccine (HDCV) is safe and recommended for preexposure prophylaxis for people at risk, including veterinarians, animal handlers, spelunkers, workers who handle the virus, and travelers to endemic areas. A total of three 1-mL doses are given IM, one each on days 0, 7, and between day 21 and 28.
Exposure is considered to be a bite that breaks the skin or any contact between mucous membrane or broken skin and animal saliva. If exposure occurs, prompt, meticulously executed prophylaxis almost always prevents human rabies. The wound is cleansed immediately and thoroughly with soap and water or benzalkonium chloride. Deep puncture wounds are flushed with soapy water using moderate pressure. Wounds are usually left open.
Postexposure prophylaxis (PEP) with rabies vaccine and rabies immune globulin (RIG) is given depending on the biting animal and circumstances (see Table: Rabies Postexposure Prophylaxis). PEP is begun, and the animal’s brain is tested for virus. Local or state health departments or the Centers for Disease Control and Prevention usually conduct testing and can advise on other treatment issues.
Rabies Postexposure Prophylaxis
For PEP, RIG 20 IU/kg is infiltrated around the wound for passive immunization; if injection volume is too much for distal areas (eg, fingers, nose), some RIG may be given IM. This treatment is accompanied by HDCV for active immunization. HDCV is given in a series of four 1-mL IM injections (deltoid area is preferred), beginning on the day of exposure (day 0), in a limb other than the one used for RIG. Subsequent injections occur on days 3, 7, and 14; immunosuppressed patients receive a 5th dose on day 28. Rarely, a serious systemic or neuroparalytic reaction occurs; then, completion of vaccination is weighed against the patient’s risk of developing rabies. Rabies antibody titer is measured to help assess risk of stopping vaccination.
PEP for a person previously vaccinated against rabies includes 1-mL IM injections of HDCV on days 0 and 3 but no RIG.
Worldwide, rabies still causes tens of thousands of deaths yearly, mostly in Latin America, Africa, and Asia, where canine rabies is endemic.
In the US, rabies kills only a few people yearly; it is usually transmitted by bats, but possibly by racoons, skunks, or foxes.
Pain and/or paresthesias at the bite site are followed by encephalitis (causing restlessness and agitation) or by ascending paralysis.
Biopsy neck skin or do PCR of saliva, CSF, or tissue if patients have unexplained encephalitis or ascending paralysis.
Treat patients supportively.
Before exposure, give the rabies vaccine to people at risk (eg, veterinarians, animal handlers, spelunkers, workers who handle the virus, travelers to endemic areas).
After exposure, thoroughly clean and debride wounds, then give the rabies vaccine and rabies immune globulin.
Drug NameSelect Trade
midazolamNo US brand name
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