Human Rabies -- California, 1992

On May 8, 1992, an 11-year-old boy died of rabies encephalitis in Fresno County, California. This was the 10th case of human rabies in the United States since 1980 known to be acquired outside the country and the first case reported in California since 1987. This report summarizes the investigation of the case.

On April 21, 1 day after he sustained a shoulder injury, the boy was evaluated at an outpatient clinic and treated with acetaminophen and codeine. On April 22, he refused to drink water with his medication; the next morning, he could not bathe because he was afraid of water. His hydrophobia and anxiety increased, and he was examined in another outpatient clinic; that evening he was evaluated in an emergency room, where he began hallucinating. Because of combativeness, excessive salivation, and respiratory distress, the patient required sedation, intubation, and ventilatory assistance. A fever of 105.4 F (40.8 C) was recorded on April 24; computed tomography of the brain and cerebrospinal fluid (CSF) analysis were normal. He subsequently experienced two episodes of cardiac arrest and was successfully resuscitated. Because rabies had been considered in the differential diagnosis, on April 24, 1 dose (800 IU) of human rabies immune globulin (HRIG) and 1 mL of human diploid cell rabies vaccine (HDCV) were administered intramuscularly, and he was transferred to a pediatric hospital.

At the pediatric hospital, the patient was hemodynamically unstable, and studies were consistent with myocarditis. Carnitine and acyclovir were administered for cardiomyopathy and rabies encephalitis, respectively. The patient's neurologic condition worsened during the next 14 days; after evidence that brain and brainstem activity had ceased, the patient was pronounced dead on May 8.

Serum specimens obtained before the administration of HRIG and HDCV were negative for rabies antibody at the California Department of Health Services' Viral and Rickettsial Disease Laboratory (VRDL). Although a skin biopsy obtained from the nape of the neck on April 24 was negative for rabies antigen by a direct fluorescent antibody (DFA) test at CDC, a skin biopsy taken on April 28 was positive. Antemortem tests for other causes of encephalitis were negative, and postmortem DFA tests on brain samples were positive for rabies antigen in the Fresno County Public Health Laboratory, the VRDL, and CDC. Characterization of the virus isolate from the patient by monoclonal antibody assay and nucleotide sequence analysis showed the virus to be similar to that found in dogs in Pakistan and India.

The patient was born in India and moved to the United States 2 years before onset of illness. He traveled to India in December 1991 and returned to the United States in February 1992. During that visit, he was bitten on the finger by a stray dog. A local pharmacist gave him a bandage to apply to the wound site. He did not receive proper wound care or rabies postexposure treatment and did not report the bite to his parents. No other family member who traveled to India with the patient had contact with the dog.

During April 8-10, the patient traveled to Tuolumne County in central California with his classmates and teacher for a camping trip. Extensive interviews with his teacher, friends, family members, and local animal-control officials did not reveal any exposure to a wild or domestic animal during this trip.

Based on extensive interviews and evaluation, three family members and 14 health-care workers from the two facilities where the patient was hospitalized were identified as having contact with potentially infectious material (e.g., saliva, CSF, or nerve tissue) from the patient. Rabies postexposure treatment was initiated for all 17 persons.

Reported by: T Tighe, MD, T Hansen, MD, Valley Children's Hospital; B Carmona, MS, B Fujikawa, DrPH, HF Stallworth, MD, Fresno County Dept of Health; RW Emmons, MD, KR Reilly, DVM, L Barrett, DVM, RA Murray, DrPH, RR Roberto, MD, GW Rutherford, MD, State Epidemiologist, California Dept of Health Svcs. Div of Field Epidemiology, Epidemiology Program Office; Viral and Rickettsial Zoonoses Br, Div of Viral and Rickettsial Diseases, National Center for Infectious Diseases, CDC.

Editorial Note

Editorial Note: Diagnosis of human rabies is difficult because of the nonspecific initial clinical presentation. This patient's hydrophobia, copious salivation, and hallucinations resulted in an early suspicion of rabies even in the initial absence of a definite history of exposure to rabies. Early suspicion of rabies, as in this case, permits the rapid institution of isolation measures, therefore reducing the number of persons potentially exposed to the rabies virus and the overall costs of postexposure treatment.

Rabies should be considered in any case of encephalitis or myelitis of unknown etiology, even in the absence of an exposure history, especially in persons who have lived or traveled outside the United States. In the United States, state and local health departments should be consulted for assistance in reviewing the techniques for diagnosing rabies and treating any person potentially exposed to rabies. U.S. citizens requiring assistance outside the United States can contact a U.S. embassy or consulate.

The risk for rabies transmission to health-care workers caring for patients with rabies is low (1,2). Postexposure treatment is recommended after contact with human rabies only if a bite or nonbite exposure (e.g., contamination of abraded skin or mucous membranes with saliva, nerve tissue, urine sediments, or other potentially infectious material) can be documented. Persons who have been bitten by animals suspected or proven rabid should begin treatment within 24 hours. Because vaccine and HRIG administered after onset of disease is of no known benefit, postexposure treatment for patients after onset of clinical rabies is not recommended.

In experimental studies, interferon alpha has offered protection against rabies virus only when administered before or shortly after virus challenge (3,4). Once clinical disease develops, the use of carnitine, acyclovir, or any other drug for rabies treatment is not recommended because there is no evidence that any pharmacologic intervention is effective for the treatment of human rabies.

This case emphasizes the importance of providing rabies preexposure prophylaxis to travelers who plan visits of more than 30 days to India or other countries where rabies is enzootic (5).

References

1. Anderson LJ, Winkler WG, Vernon AA, Helmick CG, Roberts MR. Prophylaxis for persons in contact with patients who have rabies. N Engl J Med 1980;302:967-8.

2. CDC. Human rabies diagnosed 2 months postmortem -- Texas. MMWR 1985;34:700,705-7.

3. Hilfenhaus J, Weinmann E, Majer M, Barth R, Jaeger O. Administration of human interferon to rabies virus-infected monkeys after exposure. J Infect Dis 1977;155:846-9.

4. Baer GM, Shaddock JH, Moore SA, Yager PA, Baron SS, Levy HB. Successful prophylaxis against rabies in mice and rhesus monkeys: the interferon system and vaccine. J Infect Dis 1977;136:286-91.

5. CDC. Health information for international travel, 1991. Atlanta: US Department of Health and Human Services, Public Health Service, 1991:113-6; DHHS publication no. (CDC)91-8280.

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