Failure of postexposure prophylaxis in a girl child attacked by rabid dog severing her facial nerve causing possible direct entry of rabies virus into the facial nerve

Abstract

On January 4, 2019 an eight-year-old girl child was bitten by a suspected rabid dog over the left parotid region. After a 17-h delay, the child was brought for rabies postexposure prophylaxis (PEP) at Civil Hospital Theog and was administered complete PEP. On January 29, 2019, the child was again brought to Theog Hospital with complaints of having fever, difficulty in walking, neck drop, and ptosis. On examination, pediatrician found photophobia, phonophobia, and hydrophobia and subsequently the patient died of cardiac arrest. On postmortem examination, the facial nerve was found dissected and injured at the inner end of the parotid gland. A severed end toward the brain was swollen and edematous. The entire brain was extracted and sent to Central Research Institute Kasauli for confirmation of rabies, where it tested positive for rabies by Fluorescent Antibodies Test and Biological Test. In situations where sensitive parts such as the face are involved, a thorough wound wash with soap and water and application of antiseptics along with immediate PEP may save some lives by not allowing the virus enough time to attach to and infect the nerve cells.

WHO Needs to Re-look at Animal Bite Wound Classification for Rabies Post Exposure Prophylaxis to Save People from Deadly Rabies!

“…This PEP failure in a girl child could have been due to many reasons, such as a) there was a delay of 17 hours in seeking PEP, b) the parents of the 8 years old girl child did not immediately wash the wound, c) there was facial nerve involvement, and d) maybe all the wounds were not infiltrated with sufficient eRIG till depth. 17 Animal experiments have proven that even diluted RIG can save lives in experimentally infected mice. 18 We have also used diluted eRIG in many cases having wounds on the head and neck without failure and have advocated that even a small volume of RIG covering the surface of the wound till depth is effective for rabies PEP.…”

Time to Revise the WHO Categories for Severe Rabies Virus Exposures–Category IV?

“…True failures of PEP have occurred, although these are admittedly rare, considering that rabies has the highest case-fatality of any infectious disease [ 11 , 12 , 20 ].…”

“…We think neuroanatomy is also relevant in consideration of Category IV exposures. Recently, Bharti et al reported a rabies case in a child whose facial nerve was severed, with the postmortem findings of facial nerve dissection at the parotid gland, with noted pathology of swelling and edema of the nerve stump [ 20 ]. Such an exposure is quite serious.…”

Human rabies: prospects for elimination

“…Integrated Bite Case Management (IBCM) is a recent approach in rabies control for reducing human deaths through enhancing prudent use of PEP. IBCM is a "One Health" approach that aims to establish the health status of the biting animal to inform PEP use [60,91] and reduce human deaths while minimizing unwarranted PEP use [92][93][94]. IBCM has potential to reduce overuse of PEP in lowrisk settings [78], and improve access to PEP in high-risk settings [34].…”