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Epidemiologic Notes and Reports Human Rabies -- Michigan

The first case of human rabies acquired in the United States since May 1981 occurred recently in Michigan. The patient, a 5-year-old female, possibly bitten by a bat in late August 1982, died on March 9, 1983, 32 days after onset of symptoms.

The child developed right-arm pain and fever after a fall. On February 7, an acute sprain of the right arm was diagnosed. By February 11, she had malaise, anorexia, sore throat, left-heel pain, and right-arm weakness. She appeared ill but was alert and cooperative after hospitalization, and had point tenderness at her right wrist, elbow, shoulder, and left heel. The white blood cell (WBC) count was 12,800, and a bone scan of the right wrist showed evidence of osteomyelitis. Over the next 48 hours, she became irritable, with temperatures to 39.3 C (103.9 F), progressive right-arm weakness, urinary incontinence, and difficulty swallowing saliva and water.

On February 13, she became lethargic and hypertensive, and was transferred to another hospital. Rabies was considered, but no clear history of animal exposure could be obtained. Cerebrospinal fluid (CSF) revealed 10 WBC and negative bacterial cultures. CAT and brain scans were normal; an EEG was diffusely abnormal without focal findings. The next day, she became obtunded and developed progressive respiratory distress requiring mechanical ventiliation. The presumptive diagnosis was post-infectious encephalopathy, and treatment with high-dose steroids was initiated. By February 17, she was comatose.

On February 23, the family remembered a possible bat bite in late August 1982.

Sera collected on February 23, 18 days after the onset of symptoms, showed low titers of rabies antibody by rapid fluorescent focus inhibition test (RFFIT) and by immunoadherence hemagglutination (IAHA) at the Michigan Department of Public Health (MDPH). Antibody was not present in the CSF. Since skin biopsy and mouse inoculation were negative, the serum results were not considered sufficient to confirm the diagnosis of rabies. Sera and CSF collected around February 28, showed no titer rise, but on March 4, the serum and CSF showed rises to 1:25 and 1:17, respectively, by RFFIT. A presumptive diagnosis of rabies was made. On March 9, the patient had a cardiac arrest and died. The MDPH identified rabies virus from the brain by direct FA. Of 254 persons at the two hospitals who had contact with potentially infectious secretions from the patient, 54 received post-exposure prophylaxis. Reported by FW Moler, MD, Community Health Center of Branch County, BC Johnson, MD, Branch-Hillsdale-St. Joseph District Health Dept, Coldwater, E Daniel, MD, J Gilsdorf, MD, TC Shope, MD, Mott Children's-University of Michigan Hospitals, Ann Arbor, D Budzko, PhD, GH Burgoyne, PhD, BS Berlin, MD, GR Anderson, DVM, B Wentworth, PhD, D Coohon, DVM, KR Wilcox, MD, State Epidemiologist, Michigan State Dept of Public Health; Div of Field Svcs, Epidemiology Program Office, Div of Viral Diseases, Center for Infectious Diseases, CDC.

Editorial Note

Editorial Note: This is the first case of human rabies reported in Michigan since 1948. Despite its rarity, rabies should be considered in any undiagnosed neurologic disease. No source of exposure has been identified in approximately 40% of human cases in the United States in the past 10 years.

Without treatment, rabies antibody titers typically rise to levels of 1:10,000-1:60,000. Concurrent steroid therapy has been shown to prevent antibody formation in rabies vaccine recipients (1), and like interferon, appears to have little effect on clinical illness.

The IAHA test, recently developed at MDPH (2), was used here as a rapid diagnostic aid. Results can be obtained in approximately 4 hours. This test currently has had limited field evaluation, and further assessment of its value in rabies diagnosis is needed.

References

  1. Burns KF, Shelton DF, Lukeman JM, Grogan EW. Cortisone and ACTH impairment of response to rabies vaccine. Public Health Rep 1960;75(5):441-5.

  2. Budzko DB, Charamella LJ, Jelinek D, Anderson GR. Rapid test for detection of rabies antibody in human serum. J Clin Microbiol 1983;17(3):481-4.

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