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Epidemiologic Notes and Reports Human Rabies -- Rwanda

On May 7, 1981, a 29-year-old American woman living in Kigali, Rwanda, was bitten several times on the right foot and probably the left hand by a dog that later escaped. The patient immediately sought medical attention. Her wounds were sutured, and the first dose of human diploid cell vaccine was given intramuscularly later that morning (day 0) and on days 3, 7, and 14. No human rabies globulin was given at that time. Twenty-two days later, she had fever and paresthesias of the left arm and rapidly became lethargic with paresis of arms and legs, dysarthria, and bilaterial facial paresis. She was flown to a Belgian hospital 26 days after the bites, where she was treated intramuscularly with 20 International Units (IU) of human rabies immune globulin/kg body weight. She rapidly developed a flaccid quadraplegia and coma, and died 62 days after being bitten.

Immunofluorescence and isolation studies for rabies virus were negative; however, rabies antibody titer was 827 IU/ml in the serum, and 82 IU/ml in the cerebrospinal fluid (CSF). No previous exposure to another animal was reported. Reported by J Devriendt, MD, M Staroukine, MD, Hospital Universitaire Brugmann, Brussels, Belgium; Viral Diseases Div, Center for Infectious Diseases, CDC.

Editorial Note

Editorial Note: Rabies antibody, especially in such high titers, has not been reported in the CSF of persons who have received only rabies vaccine. However, high titers of rabies antibody do occur with clinical rabies, and such high CSF antibody levels are commonly accepted as diagnostic for rabies. Therefore, the diagnosis of rabies is most probable for this patient. Despite the prompt and correct use of the human diploid cell rabies vaccine, human rabies immune globulin was omitted from this patient's initial post-exposure prophylactic regimen, and may be related to the failure of treatment. Studies have shown that the combination of human rabies immune globulin plus vaccine is better than either alone in preventing rabies (1,2), presumably because globulin provides passive antibody protection during the period when vaccine has not yet induced active antibody protection.

This episode, by demonstrating that even the new, highly potent human diploid cell vaccine cannot by itself prevent rabies, reinforces the need for human rabies immune globulin for all persons receiving post-exposure rabies prophylaxis who have not had prior rabies vaccination.

References

  1. Boltazard M, Bahmanyar M, Ghodssi M, Sabeti A, Gajdusek C, Rouzebbi E. Practical trail of antirabies serum in those bitten by rabid wolves. Bull WHO 1955;13:747-72.

  2. Selimov M, Boltucij L, Semenova E, Kobrinskij G, Zmusko L. Anwendung des Anti-Rabies Gama-Globulins bei Menschen, die von tollwutigen Wolfen oder anderen Tieren schwer gebissen wurden. J of Hygiene, Epidemiology, Microbiology, and Immunology 1959;3:168-80.

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