Today’s Morning Report is presented by Dr. Christopher!
Rabies
Background
- One of the deadliest viruses known – case fatality rate 100%
- Zoonotic – carried by warm blooded animals
- Fatal if post-exposure prophylaxis is not initiated prior to symptoms
- Majority of deaths occur in Asia/Africa
Pathophyisiology
- Lyssavirus – RNA virus
- Binds to muscle or nerve cells
- Virus travels along nerves to the CNS and other sites to generate symptoms
- Incubation – 2 to 12 weeks – varies depending on site of entry
- Early symptoms – non-specific – headache, malaise, fever,
- Late symptoms – seizures, myoclonus, agitation, depression, lethargy, heart failure
- Hydrophobia – saliva production is greatly increased + spasms in the muscles of the throat/larynx
- Diagnosis – clinical – PCR from skin or brain tissue
Prevention
- Vaccine developed in 1885 by Louis Pasteur – harvested from infected rabbits
- Widespread vaccination in the US has reduced deaths from 100/year to 1-2/year
Treatment
- PEP should begin as soon as possible after the presumed exposure.
- What to administer — Rabies immunoglobulin is referred to as “passive immunization”; rabies vaccine is referred to as “active immunization”.
- Vaccine alone is given for preexposure prophylaxis
- Post-exposure rabies prophylaxis, in previously unimmunized persons, should always include both passive and active immunization.
- POST Exposure prophylaxis
- Vaccine administration (4 doses) – day 0, 3, 7, 14, (28) – fifth does given if immunocompromised
- If previously vaccinated – re-vaccinate on day 0 and day 3
- Must have documented antibody titer – takes 7 days to mount antibody response
- Never administer in gluteal region (low titers noted)
- Rabies Immune Globulin (RIG)
- Pooled plasma from hyperimmunized human donors or horses (HRIG recommended, no noted transmission of infection)
- ½ life of 3 weeks
- Dose – HRIG 20u/kg; Equine RIG 40u/kg
- Should be infiltrated around the area of the wound and in an additional site other than the vaccine site
- Wound Care – most important initial step – reduces transmission by 90%
- Use a virucidal – betadyne
- Other – Tetanus PPX, ABxm,mn
- Vaccine administration (4 doses) – day 0, 3, 7, 14, (28) – fifth does given if immunocompromised
The views expressed on this blog are the author's own and do not reflect the views of their employer. Please read our full disclaimer here. Any references to clinical cases refer to patients treated at a virtual hospital, Janus General Hospital.
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Jay Khadpe MD
Editor in Chief of "The Original Kings of County"
Assistant Professor of Emergency Medicine
Assistant Residency Director
SUNY Downstate / Kings County Hospital
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