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Patient case: Rabies

Patient case: Rabies

Discussion

A 26-year-old man presents to the emergency department with fever, headache, and general malaise for the past three days. He reports tingling and pain at the site of a dog bite he sustained on his right hand about six weeks ago while traveling in a rural area. The wound was minor, and he did not seek medical attention at the time.

Over the last 24 hours, his symptoms have worsened, and he has developed difficulty swallowing, excessive salivation, and episodes of agitation. His family reports that he has become increasingly anxious and is now afraid of drinking water, gagging violently when attempting to swallow.

On examination, he is febrile (38.9°C/102°F), agitated, and hyperactive. His pupils are reactive, and he has no focal neurological deficits, but he exhibits signs of autonomic instability, including tachycardia and excessive sweating. When offered water, he has spasms of his throat muscles and appears terrified.

Given his history of an unvaccinated dog bite and the onset of progressive neurological symptoms, rabies encephalitis is suspected. Despite supportive care, his condition deteriorates rapidly, leading to coma and respiratory failure within days. The diagnosis is confirmed postmortem by brain tissue analysis, as no definitive antemortem test was available.

Questions
1. What is the most likely diagnosis in this patient?

a) Tetanus

b) Rabies

c) Meningitis

d) Encephalitis of unknown origin

2. What symptom is highly characteristic of rabies in this patient?

a) Fever and headache

b) Hyperactivity and excessive sweating

c) Hydrophobia and difficulty swallowing

d) Tingling at the bite site

3. What is the most appropriate next step in managing this patient?

a) Immediate administration of rabies vaccine

b) Administration of antiviral medications

c) Supportive care and palliative management

d) Surgical debridement of the bite wound

4. How could this patient have prevented rabies after the bite?

a) Taking antibiotics

b) Receiving rabies post-exposure prophylaxis (PEP) with vaccine and immunoglobulin

c) Avoiding contact with water and staying hydrated

d) Taking pain relievers and monitoring for symptoms

Reveal answers

Answers

1. Answer: b) Rabies

The patient’s history of an unvaccinated dog bite, followed by progressive neurological symptoms, including hydrophobia and agitation, strongly suggests rabies encephalitis.

2. Answer: c) Hydrophobia and difficulty swallowing

Hydrophobia (fear of water) and painful throat spasms are hallmark symptoms of rabies, caused by viral effects on the brainstem.

3. Answer: c) Supportive care and palliative management

Once clinical symptoms of rabies appear, the disease is nearly 100% fatal, and treatment is limited to supportive care. There is no effective cure after symptom onset.

4. Answer: b) Receiving rabies post-exposure prophylaxis (PEP) with vaccine and immunoglobulin

Rabies can be prevented if post-exposure prophylaxis (rabies vaccine + rabies immunoglobulin) is given before symptom onset, ideally immediately after the bite.