SESSION TYPE: Critical Care Student/Resident Cases
PRESENTED ON: Monday, October 22, 2012 at 01:45 PM - 03:00 PM
INTRODUCTION: We report a case of a 24 year-old male US Army soldier who presented with aerophobia, hydrophobia and ataxia - eight months after being bit by a feral dog in Afghanistan. He did not receive effective post exposure prophylaxis(PEP) for rabies however.
CASE PRESENTATION: The diagnosis of rabies was ultimately confirmed as viral antigens were detected on a nuchal skin biopsy. Furthermore, rabies viral RNA were detected in saliva, csf, and in the cornea as well. Immediately, we initiated an experimental protocol for rabies. 5 days into the treatment, acute hypoxic respiratory failure developed. Despite the use of conventional ventilatory support or high-frequency oscillator ventilation with and without nitrogen oxide, the Pa02/Fi02 ratio continued to decrease. A chest x-ray revealed bilateral interstitial infiltrates. All cultures were negative. Moreover, the patient remained afebrile and without an elevated white blood cell count. A bedside echo was performed and showed a hyperdynamic LV without signs of diastolic dysfunction. The diagnosis of severe acute respiratory distress syndrome(ARDS) was made. In this setting of refractory hypoxemia, we recommended the initiation of extracorporeal membrane oxygenation(ECMO). Oxygen saturations gradually improved. The patient was kept on ECMO for 5 days with a successful wean and ultimately placed on assist control ventilation. Unfortunately, on day-13 of the hospital course, our patient developed an inoperable intracerebral hemorrhage and care was withdrawn in the setting of a poor prognosis.
DISCUSSION: Rabies, a zoonotic disease with the highest case fatality rate of any infectious disease, presents as a challenge to health care professionals worldwide. Once symptoms develop, the management is largely supportive. The ultimate goal at this stage is to support the patient long enough until they can develop antibodies towards the virus. As a result, Intensivists have a vital role to play in managing complications such as severe ARDS that may ensue in human rabies.
CONCLUSIONS: Our case highlights the role of ECMO in treating severe ARDS secondary to rabies. To our knowledge, this is the first reported case of ECMO use in rabies and the longest any patient had lived with symptomatic dog rabies.
1) Center of Disease and Control, "Use of a Reduced (4-Dose) Vaccine Schedule for Postexposure Prophylaxis to Prevent Human Rabies." Last modified April 22,2011. http://www.cdc.gov/rabies/resources/acip_recommendations.html
2) Willoughby,R et. Al Survival after Treatment of Rabies with Induction of Coma, N Engl J Med2005; 352:2508-2514
3) Brodie,D; Bacchetta, M. Extracorporeal Membrane Oxygenation for ARDS in Adults N Engl J Med 2011 365: 1905-1914.
DISCLOSURE: The following authors have nothing to disclose: Amritpal Nat, Ioana Amzuta, Waleed Javaid, Aravind Pothineni, Amit Sharma, Namita Sharma, Dana Savici, Gregory Fink, Amitpal Nat
No Product/Research Disclosure InformationSUNY Upstate, Syracuse, NY