By Stan Deresinski, MD, FACP, FIDSA

Clinical Professor of Medicine, Stanford University

Dr. Deresinski reports no financial relationships relevant to this field of study.

SYNOPSIS: A Virginia resident who had not received pre- or post-exposure prophylaxis died of rabies resulting from a dog bite during a prolonged trip to India. Many exposed healthcare workers subsequently received post-exposure prophylaxis.

SOURCE: Murphy J, Sifri CD, Pruitt R, et al. Human rabies — Virginia, 2017. MMWR Morb Mortal Wkly Rep 2019;67:1410-1414.

A 65-year-old woman in Virginia developed right arm pain and paresthesias and presented to an urgent care center three days later, on May 6, 2017. Clinicians diagnosed carpal tunnel syndrome. The following day, the patient was evaluated at a hospital with complaints of shortness of breath, anxiety, insomnia, and difficulty swallowing water. She was deemed to be experiencing a panic attack and was given lorazepam.

On May 8, she was admitted to a different hospital with chest discomfort, shortness of breath, progressive paresthesia involving the right shoulder and arm, and increased anxiety. The serum troponin was elevated (as was lactic acid). Angiography revealed normal coronary arteries. That evening, the patient became progressively agitated and combative and was noted to be gasping for air when attempting to drink water. This apparently led to questioning about animal exposures. Her husband reported that she had been bitten by a puppy in India six weeks previously. The patient had been part of a yoga tour in India from Jan. 28 to April 5, 2017, that included rural areas. It was confirmed that she had been bitten outside her hotel in Rishikesh. The wound was washed with water, but no further intervention was performed.

A diagnosis of rabies was confirmed on May 11 when rabies virus RNA was detected by RT-PCR on skin biopsy and saliva specimens, as well as rabies antigen detection on the skin specimen. Typing indicated that the virus was consistent with rabies virus circulation in dogs in India.

The patient became progressively more ill, required intubation, and died on May 21 after life support was withdrawn. An extensive and exhaustive epidemiological investigation was performed that included 250 healthcare workers, 72 (29%) of whom were advised to receive post-exposure prophylaxis. The cost of the rabies immune globulin and vaccine for this treatment was estimated at $235,000.

COMMENTARY

There is much to be learned from this unfortunate case. The patient initially received incorrect sequential clinical diagnoses of carpal tunnel syndrome, panic attacks, and coronary artery disease. This situation was associated with the potential exposure of many healthcare workers to the rabies virus until the diagnosis was made and the patient was placed in appropriate isolation.

An even more critical issue is that this patient had been a candidate for rabies vaccination prior to travel, given the prolonged visit to India, including rural areas, as recommended by CDC. After she was bitten by a dog in India (one of 122 countries in which canine rabies virus is present), the only treatment provided was washing the wound with water, rather than post-exposure prophylaxis, which would have prevented her unfortunate outcome.