Human Rabies with Initial Manifestations that Mimic Acute Brachial Neuritis and Guillain-Barré Syndrome

Abstract

IntroductionHuman rabies can be overlooked in places where this disease is now rare. Its diagnosis is further confused by a negative history of exposure (cryptogenic rabies), by a Guillain-Barré syndrome (GBS) type of presentation, or by symptoms indicating another diagnosis, eg, acute brachial neuritis (ABN).Case presentationA 19-year-old Mexican, with no past health problems, presented with a two-day history of left shoulder, arm, and chest pain. He arrived in Louisiana from Mexico five days prior to admission. Of particular importance is the absence of a history of rabies exposure and immunization. On admission, the patient had quadriparesis, areflexia, and elevated protein in the cerebrospinal fluid, prompting a diagnosis of GBS. However, emerging neurological deficits pointed towards acute encephalitis. Rabies was suspected on hospital day 11 after common causes of encephalitis (eg, arboviruses) have been excluded. The patient tested positive for rabies IgM and IgG. He died 17 days after admission. Negri bodies were detected in the patient’s brain and rabies virus antigen typing identified the vampire bat as the source of infection.ConclusionRabies should be suspected in every patient with a rapidly evolving GBS-like illness—even if there is no history of exposure and no evidence of encephalitis on presentation. The patient’s ABN-like symptoms may be equivalent to the pain experienced by rabies victims near the inoculation site.

Imported Human Rabies Cases Worldwide, 1990–2012

“…The vast majority (85.0%) of cases resulted from exposure to dogs. Three cases resulted from bat-related injuries, including one case of a Dutch tourist returning from Kenya [3]–[5], one case of a US citizen injured in the US who developed rabies symptoms while expatriated in Iraq and was subsequently evacuated to Switzerland [6], and one case of a Mexican citizen who developed rabies in the US where he was involved in seasonal work [7], [8]. One case was observed in Russia following a fox bite that occurred in Ukraine [2].…”

“…A 50-year-old French female tourist sustained multiple deep dog bites on the legs during a trip in India and developed rabies 12 days later while returning to France [9], [10]. A 19-year-old male Mexican seasonal worker was bitten by a bat on his leg and developed rabies due to a variant virus of vampire bat rabies 15 days later in the US [7], [8]. In three cases, very long incubation times were recorded.…”

“…The time between hospitalization and a confirmed diagnosis of rabies was documented in 27 out of 28 patients whose diagnosis was confirmed ante-mortem. The mean time was 7.7 days (median time: 6.0 days, range 2–30), including four cases with diagnoses delayed by 15, 16, 18 and 30 days [7], [8], [14], [16]–[18]. Reasons for delayed diagnosis were an absence of a history of animal bites at presentation in three cases and a paralytic form mimicking Guillain-Barré syndrome in three cases.…”

“…A delayed diagnosis of rabies can have adverse public health consequences including multiple transmissions of rabies via transplanted solid organs from a single infected donor whose diagnosis of rabies was retrospectively assessed [22], [34]–[36]. It may also lead to the need for risk assessment in a large number of patient contacts, as recently exemplified in Louisiana where 204 individuals were investigated by public health officials and hospital infection control staff, resulting in 95 requiring post-exposure prophylaxis, including 68 healthcare workers [7], [8]. In the present work, we observed a large heterogeneity in the use of laboratory techniques, which was due to the length of the study period and differences between countries.…”

Unusual Chief Complaint of Patient with History of Vaccination Leading to Unrecognized Human Rabies with Extreme Risk of Saliva Exposure for Medical Personnel-A Case Report and Literature Review

“…Especially in the case presented here, the chief complaint of chest pain deviated the medical team's attention/focus away from a diagnosis of rabies to heart disease. Though uncommon, such cases have been reported ( Table 2) [4][5][6][7][8] , since rabies can caused focal interstitial myocarditis as discussed by Park et al 9 In the case series reported by Mani et al 10 , all cases presented without evidence of chest pain, so the clinical presentations of rabies vary. Furthermore, concerning the classical sign of fear of water, in our case, the patient 11 In terms of the forensics aspect, since a rabies investigation is not performed on every case with an unknown cause of death examined by only external examination, the forensic physician thought of rabies infection as the cause of death based on the review of the history recorded on the first emergency room visit and the numerous dogs observed by the forensic physician at the crime scene during the post-mortem visit at the patients residence.…”