Effect Measure

A strange case of presumptive rabies

Rabies is one of those diseases that scares the crap out of me. Once clinical symptoms start, it is essentially a death sentence. “Essentially” because there are 6 cases of survival in the medial record, but 5 of the 6 had had rabies vaccination prior to illness. A single case of survival in an unvaccinated case is on record, but only after a long period in intensive care. Now CDC is reporting an unusual case they are calling “abortive rabies.” The patient was a 17 year old girl who had multiple hospitalizations for a variety of neurologic symptoms, including severe headache, vomiting and weakness and numbness in her right arm. After diagnostic work-ups were unsuccessful in identifying the cause, a history of exposure to bats 2 months before symptom onset was revealed. She had gone on a camping trip in Texas and entered a large cave with flying bats, several of which hit her body. She wasn’t aware of any bites or scratches. She also kept pet ferrets and a dog, but all were in good health. At this point rabies was considered and tests showed she had anti-rabies antibodies, although no virus or viral antigens were detected. At that point she got a dose or rabies vaccine and a course of human rabies immune globulin.

This young woman was sick but never sick enough to require intensive care. She was discharged after a week with her symptoms resolved, but came back to the emergency room a week later complaining of recurring headache. She left before a spinal tap could be done but came back again a week later with headache and vomiting. This time a spinal tap was performed and showed increased pressure but her headaches resolved and she wasn’t admitted. She was then lost to follow-up and could not be contacted again. Her boyfriend received rabies prophylaxis.

This is a very strange report. Since no viral genetic material was detected and her clinical course was, to say the least, unusual for rabies, it remains possible this was not rabies but an agent with cross-reacting antibodies. However she had an exposure history, relevant serology and no obvious alternative diagnosis. We have very little human rabies in North America but in Asia and Africa rabies cases and hence deaths are estimated by WHO to be around 55,000 a year. It is quite plausible that “abortive rabies” occurs without being reported. Some people, for whatever reason, may mount a more timely and vigorous immune response that prevents the catastrophic effects of the disease. Once symptoms start, with the exceptions noted, the result is virtually always fatal, but there is a several week interval after being bitten or exposed to a rabid animal where post exposure prophylaxis is highly effective in preventing onset of the the disease.

So there are things we know can be done, including vaccinating animals against rabies and post exposure prophylaxis. These things work. If you want an example of things that probably don’t work (although I’ll stop short of saying it’s impossible), here’s one:

A labourer in Jharkhand, who was bitten by a street dog, killed the animal, cut out its heart and ate it to protect himself from rabies.

After the dog bit him Saturday, Chukna Ganju, 30, a resident of Dakra village, on the outskirts of Ranchi, caught hold of the animal and killed it by flinging it on stones, local media reports said Sunday.

When the dog died, he removed its heart with the help of a pair of scissors and ate it raw. The dog had bitten him several times during the course of being killed.

“Now, there will be no effect of rabies on my body,” Chukna was quoted as saying by the local media. According to him, he did not need medical help as he did the treatment by eating the heart of the dog. (New Kerala)

Comments

  1. #1 Dylan
    February 28, 2010

    Chukna then went on to establish the community’s first clinic to successfully incorporate the practice of novel forms of Homeopathic Medicine, along with Mixed Martial Arts.

  2. #2 Alex
    February 28, 2010

    Concerning the last example, it’s actually not surprising that he believed that the animal’s heart could save him. Remember the Aztecs in Tenochtitlan? Why were they disecting their fellow human beings before the altar and eating their hearts? They believed it would bring them immortality and cure diseases. Sometimes, it’s fun to see that hilarious religious nonsense attempt to make a comeback in daily life. That said, I feel bad for the dog.

  3. #3 Uncle Glenny
    February 28, 2010

    More plausible than homeopathy.

  4. #4 geodoc
    February 28, 2010

    Interesting.

    Could it have been a bat lyssavirus rather than ‘classic’ rabies? Got no idea how accurate the serology testing is in distinguishing between antibodies.

    Coincidentally, I’ve been looking around a great website today (www.worldmapper.org) and found this cartogram of global rabies deaths— shoes how badly India is affected by the disease:
    http://www.worldmapper.org/images/largepng/237.png

  5. #5 revere
    February 28, 2010

    geodoc: According to CDC, the only bat lyssa viruses aren’t in the US and she had no foreign travel. Kent Cave Virus found in US bats will cross react but she had no sign of viral antigen from KCV, so they seem to be discounting that. But this is either very unusual or there is a lot we haven’t been seeing elsewhere.

  6. #6 Lisa the GP
    February 28, 2010

    Is it possible that some form of spontaneous killed-virus vaccination occurred?

    I’m wondering if she inhaled aerosolized guano that (if the viral proteins hadn’t completely degraded yet) could have provoked an immune response to some of the rabies proteins. That might account for her having reacting antibodies, whether she ever had the actual virus or not.

    If she did have virus in addition, and if any of those antibodies happened to be protective, then that might account for her survival, similar to the survival of those who have been formally vaccinated.

    Its theoretically possible but I don’t know how likely it is. What do you think?

  7. #7 revere
    February 28, 2010

    Lisa: Could be. I have no idea and it doesn’t sound like CDC does either. Even eating the dog’s heart might have an effect (but I wouldn’t count on it).

  8. #8 Dr. Jordan
    March 1, 2010

    Interesting that everyone of the five confirmed rabies cases had innoculations prior to infection with rabies, I guess that prooves vaccines are not protective, not the golden chalice of immunity and safety we are brainwashed into believing.
    Now, search out the number of rabie cases both in animals and humans that came from innoculations, vaccines to prevent rabies! Just last week, they were reporting on a dog vaccinated five years in a row for rabies protection, breaks with rabies infection and they use this as a news artilcle to support everyone bringing in their animals for rabies shots…….can we not see?

  9. #9 C. Corax
    March 1, 2010

    “Dr.” Jordan emits: “I guess that prooves (sic) vaccines are not protective.”

    I’ve got an idea. We’ll compare the outcome for those five patients with the outcome for five anti-vaxxers who will volunteer to be bitten by a rabid animal.

    After the five anti-vaxxers die horrific deaths, we’ll continue the discussion with you on the protective value of vaccines.

  10. #10 Nemo
    March 1, 2010

    Not prior to infection, dumbass — prior to illness. They were exposed, then vaccinated.

  11. #11 antipodean
    March 1, 2010

    Ha ha

    Her website has the quack disclaimer on the front page.

    Graduates of the North Carolina Vet school beware that your qualifcation is now devalued. Ignorant.

  12. #12 Escuerd
    March 1, 2010

    Dr. Jordan, I think the basic issue that you’re forgetting to take into account is that you’re a retard who lacks reading comprehension and the ability to think quantitatively.

    Rabies vaccines are often administered after potential exposure, but before the onset of illness, because the virus usually takes some time to get to the central nervous system where it does the most serious damage.

    What’s more, vaccines don’t have to be 100% preventative to be effective. It’s disingenuous to pretend that something that decreases the probability of getting a disease is useless just because it doesn’t prevent every case.

    Hope that helps.

  13. #13 CraigR
    March 1, 2010

    Whenever I read about these cases in MMWR I’m always amazed at how long it took for someone to test the patient for rabies. Hindsight is 20/20 of course, but given symptoms that are often classic, it should have been part of the differential earlier rather than later. If I’m ever admitted for unexplained neurological symptoms, I’ll ask through my foaming mouth for serology on day one!

  14. #14 Calli Arcale
    March 2, 2010

    Alex @ 2:

    Concerning the last example, it’s actually not surprising that he believed that the animal’s heart could save him. Remember the Aztecs in Tenochtitlan? Why were they disecting their fellow human beings before the altar and eating their hearts? They believed it would bring them immortality and cure diseases. Sometimes, it’s fun to see that hilarious religious nonsense attempt to make a comeback in daily life. That said, I feel bad for the dog.

    Many cultures have believed that eating the flesh of one’s enemies would make them stronger. (There is a tribe in Africa which still practices cannibalism. It’s not for strength, though; they believe it is the only way to completely destroy a witch.) However, it is not at all clear whether the Aztecs were among them. That wasn’t the primary reason Mesoamerican cultures practiced human sacrifice, certainly. The intent was primarily to feed the gods by returning life force to them, thus keeping the universe alive. They seriously believed the world would end if the gods were not adequately fed, so I am dubious of some claims that elite Aztecs were allowed to eat the hearts. It would diminish the value of the sacrifice, and valuable sacrifices appeared to be extraordinarily important to them.

  15. #15 jay
    March 5, 2010

    Just last week, they were reporting on a dog vaccinated five years in a row for rabies protection, breaks with rabies infection and they use this as a news artilcle to support everyone bringing in their animals for rabies shots…….can we not see?

    Duh? Can you not see? This MADE THE NEWS exactly because it so EXTREMELY RARE. Outdoor dogs by the millions are potential exposed to rabies and so few become infected because the protection is so effective. Try that with a few million unvaccinated dogs and see how many cases you see.

    If only seatbelts were as effective as rabies vaccines!

  16. #16 rijkswaanvijand
    March 6, 2010

    Let’s put ds Jordan in the non-vac group!

  17. #17 Skeptic Ginger
    March 6, 2010

    Posted by CraigR
    Whenever I read about these cases in MMWR I’m always amazed at how long it took for someone to test the patient for rabies. Hindsight is 20/20 of course, but given symptoms that are often classic, it should have been part of the differential earlier rather than later. If I’m ever admitted for unexplained neurological symptoms, I’ll ask through my foaming mouth for serology on day one!

    As an occupational infectious disease practitioner, I’m also amazed at how many health care workers need rabies prophylaxis after these cases. While some of the treatments are probably more for rabies paranoia, one still has to wonder how it is that dozens of health care workers can all be that careless around the saliva of a patient with a severe encephalitis of an unknown etiology. Not to mention you’d think the hospitals involved would have very strict protocols for such patients given rabies prophy which includes Rabies Immunoglobulin is about $1,000 a pop.

    Yet it is often the case that each incident teaches only those immediately involved. We fail to spread these lessons very far from the tree.

    The other aspect of this story which seriously concerns me is that this patient was lost to follow up. Public Health would have been notified of the lab result by the lab or the hospital staff, (or maybe the PHD lab was the lab used). Did they do any other contact tracing other than treating the boyfriend? Did they do any follow up labs to confirm the original tests and/or monitor for viremia?

    Perhaps the article writer was not aware of PHD actions taken in addition to the hospital’s. I can’t imagine our local PHD being so casual as to lose a rabies case to follow up.