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Public Health Dispatch: Human Rabies --- Québec, Canada, 2000

On September 22, 2000, a 9-year-old boy awoke with a fever and complained of pain in his upper left arm. The pain persisted, and he developed insomnia and tremors in his left arm and hand. He was admitted to a local hospital on September 27. That evening, he had mild dysphagia, pruritus of his upper chest and back, and a transient macular rash. On September 28, he developed tremors and myoclonic jerks in both arms, had become agitated, and had hydrophobia, aerophobia, dysarthria, and visual hallucinations. The next day hypersalivation was observed and the tremors and myoclonus had spread to his lower extremities. He became very anxious, indicated that he was suffocating, and underwent endotracheal intubation. A diagnosis of rabies was considered and he was transferred to a children's hospital. Laboratory findings were normal except a mildly elevated cerebral spinal fluid protein. An electroencephalogram indicated no epileptiform activity. Head magnetic resonance imaging was normal. On September 29, the results of the rabies tests were positive, and rabies immune globulin and vaccine were administered to the patient. His neurologic and hemodynamic status deteriorated, and he died on October 6.

A nuchal skin biopsy tested positive by direct fluorescent antibody test. Rabies virus was isolated from the saliva, and saliva, tears, and skin biopsy were positive for rabies by reverse transcriptase-polymerase chain reaction. Molecular analysis of the virus revealed a rabies variant associated with silver-haired (Lasionycteris noctivagans) and eastern pipistrelle (Pipistrellus subflavus) bats.

During August, the patient visited a zoo and went to a day camp where he observed bats that had been captive for many years. No history of substantial exposure to bats or other animals occurred in these places. On August 28, while the patient and his brother were sleeping in a rural cottage, his parents found a bat in the kitchen. The same evening, the patient's brother went into the bathroom and observed a bat that seemed to have difficulty flying. He alerted his father who removed it from the cottage with his bare hands. Approximately 3 days later, the patient showed his mother a 0.8-inch (2 cm) erythematous lesion with a small central laceration on his upper left arm. No action was taken. After the diagnosis was made, rabies postexposure prophylaxis was offered to the patient's parents and brother. Prophylaxis also was given to 44 health-care providers because of possible percutaneous or mucous membrane exposure to the patient's saliva and to 12 playmates possibly exposed to the patient's saliva. This human death from rabies was the first one reported in Canada since 1985.

Reported by: N Turgeon, MD, M Tucci, MD, Sainte-Justine Hospital; J Teitelbaum, MD, Maisonneuve-Rosemont Hospital; D Deshaies, MD, PA Pilon, MD, J Carsley, MD, L Valiquette, MD, Montréal-Centre Dept of Public Health, Montréal, Québec. H Arruda, MD, L Alain, MSc, Ministry of Health and Social Svcs, Québec, Canada. AC Jackson, MD, Kingston General Hospital; A Wandeler, PhD, Animal Diseases Research Institute, Kingston, Ontario. Viral and Rickettsial Zoonoses Br, Div of Viral and Rickettsial Diseases, National Center for Infectious Diseases; and an EIS Officer, CDC.

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