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Epidemiologic Notes and Reports Human Rabies Acquired Outside the United States

The third case of human rabies reported to CDC in 1984 was diagnosed in California in October 1984 in a 72-year-old Guatemalan citizen. The patient reported that, in an unprovoked attack in Guatemala in early June, she was bitten on her right ankle by a stray dog that could not be found for examination. On September 3, she first noted weakness of her right leg. She left Guatemala that day to visit her daughter in California. When she deplaned in California that evening, she was unable to walk without assistance. By September 6, she was unable to stand and was hospitalized.

At the time of admission, the patient was alert, communicative, and afebrile. She reported receiving shots at the time of her bite and was thought to have received rabies postexposure prophylaxis. The only abnormality detected on physical examination was right lower extremity weakness. Agitation and confusion developed on the night of admission. Computerized tomographic examination of her head was unremarkable. On September 9, a lumbar puncture revealed a cerebrospinal fluid white blood cell count of 6 lymphocytes per mm((3)), an elevated protein (65 mg/dl), and a normal glucose. Later that day, she developed aspiration pneumonia and required mechanical ventilation. Paralysis progressed to involve all extremities, and her mental status declined. Despite supportive care, she became comatose and died October 1.

At autopsy, because of the clinical course of progressive encephalitis, brain tissue was examined and found positive for rabies by direct fluorescent antibody testing. Questioning of family members revealed that, following the dog bite, the patient had received only local wound care and a single intramuscular injection (presumably tetanus toxoid). The delay in diagnosis necessitated administering postexposure prophylaxis to 179 persons exposed to the patient, including 12 family members. Adapted from California Morbidity (November 9, 1984); reported by Div of Viral Diseases, Center for Infectious Diseases, CDC.

Editorial Note

Editorial Note:Ten (43%) of the 23 human rabies cases reported to CDC from 1975 through 1984 were acquired outside the United States; these include six acquired by U.S. citizens living outside the United States and four acquired by non-U.S. citizens outside the United States and diagnosed in the United States. There were histories of probable exposure to rabies from a dog bite in eight of the 10 cases. In the eight cases, the development of rabies was attributable to: failure to seek treatment (three cases), postexposure therapy not recommended (two), delay in seeking treatment (one), failure to receive rabies immune globulin as part of postexposure therapy (one), and misdiagnosis of the exposing animal (one).

All persons traveling to rabies-endemic areas outside the United States should be made aware of the risk of exposure to rabies and the importance of local wound treatment, medical advice, and rabies biologics. Persons traveling to developing countries where rabies control programs for domestic animals are not optimal should be offered preexposure prophylaxis if they plan to stay for more than 30 days (1). Every 2 years, persons on long-term international assignments in rabies-endemic areas who are at risk of an inapparent exposure to rabies or a delay in postexposure prophylaxis should be advised to have a booster or have their serum tested for rabies-neutralizing antibody and, if their titer is inadequate, have a booster. It should be emphasized that preexposure prophylaxis does not eliminate the need for prompt postexposure prophylaxis if an exposure to rabies occurs.

Rabies should be considered in any case of encephalitis or myelitis of unknown etiology, even in the absence of an exposure history, particularly in a person who has lived or traveled outside the United States.

In the United States, state health departments should be consulted for assistance in reviewing the techniques for diagnosing rabies in suspected rabid animals and the therapeutic measures received by any person exposed to rabies outside the United States. If assistance is needed outside the United States, a United States Embassy or consulate can be contacted.


  1. ACIP. Rabies prevention--United States, 1984. MMWR 1984;33:393-408.

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