CASE HISTORY 2

A 4 year old girl developed drowsiness, listlessness, abdominal pain, anorexia, sore throat, nasal congestion, drooling, and pain on the left side of the neck for 2 days. The following day, she developed fever to 104oF and behavioral changes. She had hallucinations, difficulty standing, insomnia, and refused to drink liquids. Other vital signs included pulse 210 and respiratory rate 32. WBC count was 20,800/mm3. Her initial diagnosis was possible drug ingestion. Urine toxicology screen was negative. A head CT scan was normal. She then developed a seizure and bradycardia, requiring cardiopulmonary resuscitation. She was transferred to an ICU with diagnosis of sepsis, encephalitis, or drug ingestion. Ceftriaxone and acyclovir were started. She developed coma and an EEG showed generalized sharp and slow wave discharges. Nine days after the onset of symptoms, she died.

During the hospitalization, family members reported that approximately three weeks prior to the onset of symptoms, a bat had been found in the child=s bedroom. The child had no obvious bite wounds and told her family that she had not been bitten by the bat. The family did not seek medical advice at that time and buried the bat in their backyard.

The child's autopsy showed severe cerebral edema and brain herniation. Intracytoplasmic inclusions were present in the brain and spinal cord. Brain tissue and a nuchal skin biopsy sample taken one day prior to death were positive for rabies antigen by direct fluorescent antibody testing. The health department exhumed the bat. Nucleotide sequence analysis of sample generated by RT-PCR from the bat and the patient were identical.

This is a true case which occurred in the state of Washington. Another interesting case involving a kitten in a pet store is in the optional reading.

Questions

1. Should the patient have been in isolation? What was done for exposed contacts?

2. What is the incubation period for rabies?

3. Why is it difficult to diagnose this infection? What clinical symptom did this patient have which is classic for rabies (but is not always present)?

4. If the family had reported finding the bat in the patient=s room immediately to the physician or health department, what treatment would the patient have received?

5. Who should routinely receive rabies virus vaccine?