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Human Rabies -- Florida, 1996

On February 8, 1996, a 26-year-old man died in a hospital in Naples, Florida, following progressive neurologic deterioration. Rabies had been clinically suspected on the day he was admitted (December 30, 1995) and was confirmed by CDC on January 10, 1996. This report summarizes the investigation of this case by the Florida Department of Health and Rehabilitative Services, Collier County Public Health Unit, which indicated a dog in Mexico as the probable source of exposure.

The patient was a citizen of Mexico who entered the United States on Decem ber 4, 1995. He sought care from a private physician in Immokalee, Florida, on December 29 because of anxiety, difficulty breathing while speaking, left lower-quadrant abdominal pain, left leg pain, lower back pain, and lethargy. Findings on physical examination included injected conjunctivae, a temperature of 96.3 F (35.7 C), pulse of 112 beats per minute, and rebound tenderness to the abdomen. On referral from his physician, the patient was transported by ambulance to a regional hospital emergency department (ED). On arrival at the ED, bowel sounds were slightly increased, and a neurologic examination was within normal limits. Constipation was diagnosed, and he was treated with a tap water enema. Following a bowel movement, the patient reported that he felt better, and he was released.

On December 30, the patient was transported by ambulance to the ED after complaining of vague abdominal discomfort and an inability to eat during the preceding 3 days. Despite being hungry and thirsty, he had been unable to swallow. When offered water, he became anxious and hyperventilated.

Physical examination findings were normal except for an oral temperature of 100.3 F (37.9 C) and a rectal temperature of 102.0 F (38.9 C). Abnormal laboratory findings included a white blood cell count of 20,800/mm3 (normal: 5000/mm3-10,000/mm3), blood gas pCO2 of 25 mm Hg (normal: 35 mm Hg-45 mm Hg), blood glucose of 142 mg/dL (normal: less than 140 mg/dL), and a total serum bilirubin of 1.8 mg/dL (normal: 0.3 mg/dL-1.0 mg/dL). Chest and pelvic radiographs and a computerized tomography of the brain were normal.

During the following 2-3 hours in the ED, the patient became disoriented and agitated. During a lumbar puncture procedure, he jumped off the stretcher and became violent. After being restrained, he continued to scream and spit. He was intubated, admitted to the intensive-care unit (ICU), and treated with midazolam and haloperidol. Rabies was suspected, and therapies of ceftriaxone, vancomycin, acyclovir, and piperacillin/tazobactam also were initiated. He was administered rabies and tetanus immunoglobulins and tetanus and diphtheria toxoids. Diagnostic tests of blood were negative for arsenic, mercury, lead, mushroom, and other toxins, and of cerebrospinal fluid for herpes simplex virus and bacteria.

On January 3, the patient was unresponsive to stimulation but did exhibit gagging-type movements. On January 4, after midazolam therapy was discontinued, he could only open his eyes and respond to facial tactile stimulation. On January 5, the patient was transferred to another hospital and admitted to the ICU where results of a magnetic resonance imaging of the lumbar spine were normal. On January 6, a full-thickness nuchal skin biopsy and a saliva sample were obtained and sent to CDC for rabies testing and, on January 10, results for both were reported as positive. Nucleotide sequence analysis conducted at CDC on January 11 of the isolate from salivary samples implicated a variant of rabies virus associated with rabid dogs near the Mexico/Guatemala border.

The patient remained on a mechanical ventilator from January 6 to February 8; additional supportive therapy included intravenous fluids and tube feedings. He was stable but unresponsive to all stimuli and exhibited cardiac arrythmias (primarily sinus tachycardia) regularly. He died on February 8. Four hospital personnel who were exposed to the patient's saliva received postexposure prophylaxis.

Although the patient denied a history of animal bites, a friend reported the patient had been bitten by a puppy in Chiapas, Mexico, during October 1995. The puppy was apparently a stray given as a gift by a neighbor and was in the household only for a few days before the bite. The patient killed the puppy at the time of the bite, and it was not tested for rabies. Further investigation by Mexican authorities could not confirm the bite incident but revealed the patient may have sustained a dog bite on his left hand in January 1995. Because canine rabies is endemic in this region of Mexico, a dog bite was considered the most likely source of exposure.

Reported by: CS Forszpaniak, MD, KS Harbourne, MD, JF Nolan, MD, J Puerto, MD, AM De La Rivaherrerra, MD, M Rubin, MD, K Taylor, MD, CW Liebert, MD, M Neumann, PhD, Naples Community Hospital, Naples; M Crowley, MS, M Laliberte, M Burton, J Polkowski, MD, Collier County Public Health Unit; G Hlady, MD, R Hopkins, MD, State Epidemiologist, Florida Dept of Health and Rehabilitative Svcs. Pan American Health Organization, Washington, DC. Director General of Preventive Medicine, Secretary of Health, Mexico. Viral and Rickettsial Zoonoses Br, Div of Viral and Rickettsial Diseases, National Center for Infectious Diseases; Div of Applied Public Health Training (proposed), Epidemiology Program Office, CDC.

Editorial Note

Editorial Note: This report describes the 29th case of human rabies reported in the United States, and the second from Florida, since 1980. Eleven (38%) of the 29 cases, including this case, are presumed to have been acquired outside the United States; all were associated with exposure to dogs.

In this case, the length of time between initial presentation and death (42 days) was substantially longer than other human rabies cases since 1980 (mean=16.2 days, standard deviation {SD}=6.8). It is unclear whether the prolonged clinical course was influenced by supportive therapies or exposure factors. Antiviral and immunoglobulin therapies have not proved efficacious in treating clinical rabies (1,2), and data do not suggest longer clinical courses in canine-associated infections.

The epidemiologic investigation of this case included the extensive use of bilingual public health investigators and medical personnel and coordination between local, state, and federal authorities. Information regarding the probable exposure history was elicited from friends and health authorities in Mexico and the Pan American Health Organization.

The number of persons receiving postexposure prophylaxis as a result of this case was substantially lower than for most other cases since 1980 (mean=64.6 treatments per case, SD=40.8), probably reflecting the patient's small number of social contacts and family members in the United States, the early suspicion of rabies as a diagnosis, and the prompt initiation and maintenance of protective barrier techniques during presentation and hospitalization.

Canine rabies remains a prevalent public health threat in many developing nations, and most human cases resulting from exposures outside the United States are associated with dog variant rabies viruses. Persons who are bitten or scratched by any animal should thoroughly wash all wounds with soap and water and seek immediate medical attention to evaluate the need for postexposure prophylaxis.

References

  1. Fishbein DB. Rabies in humans. In: Baer GM, ed. The natural history of rabies. 2nd ed. Boca Raton, Florida: CRC Press, 1991:519-49.

  2. Hemachudha T. Human rabies: clinical aspects, pathogenesis, and potential therapy. Curr Top Microbiol Immunol 1995;187:121-43.





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