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Essential Features

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  • • Viral (ssRNA rhabdovirus) encephalitis of mammals transmitted through the saliva of an infected animal

    • Humans are usually inoculated by the bite of a rabid bat, raccoon, skunk, fox, or other wild animal

    • Modes of transmission include mucous membranes (eyes, nose, mouth), aerosolization, and corneal transplantation

    • After local (primary) infection, the virus enters peripheral nerves and is transported to the CNS, making it difficult to detect (eclipse phase)

    • Subsequent incubation period varies in humans from several days to typically 1–3 months

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Epidemiology

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  • • 30% of victims have no memory or evidence of a bite

    • Only 4 of 8513 reported cases were in humans (1997)

    • Death rate: 1–4 deaths per year

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Clinical Findings

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Symptoms and Signs

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  • • Clinical symptoms begin with pain and numbness around the site of the wound

    • Nonspecific flu-like symptoms of fever, irritability, malaise, and progressive cerebral dysfunction

    • Delirium, hallucinations, insomnia, paralysis, and convulsions occur terminally

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Laboratory Findings

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  • • Direct fluorescent antibody (dFA) test on brain tissue is used most frequently to diagnose rabies in animals

    • No single test can rule out rabies absolutely

    • Serum and cerebrospinal fluid (CSF) are tested for antibodies

    • Skin biopsy is examined by dFA

    • Saliva can be tested by nested reverse transcription polymerase chain reaction (RT-PCR)

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Diagnostic Considerations

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  • • Rabies virus has distinctive bullet shape and nonsegmented, negative-stranded RNA genome

    • After local (primary) infection, the virus enters peripheral nerves and is transported to the CNS, making it difficult to detect (eclipse phase)

    • Subsequent incubation period varies in humans from several days to typically 1–3 months

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Work-up

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  • • Information useful in determining the risk of potential rabies infection includes:

    • –Geographic location of the incident

      –Type of animal involved

      –How the exposure occurred

      –Vaccination status of the animal

      –Whether the animal can be safely captured and tested for rabies

    • Test serum and CSF for antibodies

    • Skin biopsy

    • Saliva tested with RT-PCR

    • Suspected cases of rabies: Contact public health department

    • Any animal suspected of being rabid should be killed and its brain studied with a rabies-specific fluorescent antibody

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Treatment and Management

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  • • Since the established disease is almost invariably fatal, early preventive measures are essential

    • Wound should be washed thoroughly with soap and water

    • Before exposure, rabies vaccine prophylaxis

    • After exposure, vaccine plus immune globin

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Surgery

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Medications

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  • • Human rabies immune globulin

    • Human diploid cell vaccine

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Complications

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  • • Established disease is almost invariably fatal

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Prognosis

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  • • Most human deaths occur in people who fail to seek medical assistance

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Prevention

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