SESSION TYPE: Critical Care Student/Resident Case Report Posters II
PRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PM
INTRODUCTION: Rabies is a zoonotic disease caused by a bullet shaped virus, which is transmitted via saliva of infected animals, usually a bat in USA . The virus enters the CNS, causing an acute encephalomyelitis, which is almost uniformly fatal. The disease is preventable if exposure to the virus is promptly followed by wound cleaning, administration of rabies immunoglobulin and vaccination.
CASE PRESENTATION: A 24 year old male sought treatment for right hand numbness, dysphagia and vomiting for 5 days. He had history of dog bite in his hand 6 months ago while working in South East Asia and reported receiving a series of Immunoglobulin vaccine after the bite. The dog was killed and tested negative for rabies. On the day of presentation patient developed hydrophobia, aerophobia and copious salivary secretions followed by extreme agitation. CT head was normal, while CSF showed lymphocytic pleocytosis. He had a normal physical examination but was intubated for respiratory distress. Due to strong suspicion of rabies, Milwaukee protocol was started before the diagnosis was made. It included inducing therapeutic coma with midazolam, fentanyl and ketamine, along with antiviral drugs and supportive care, until the native immune response matured . Patient developed bradycardia and raised ICP, which was managed by transvenous pacemaker, and ventriculostomy drains respectively. On the 3rd day nuchal skin biopsy, saliva and serum PCR tested positive for rabies. Daily saliva and CSF samples were checked for antibody titers against the virus. Hypothermia protocol was started for neuroprotection despite of which he developed Central Diabetes Inspidus, which was treated with vasopressin. Later on he developed ARDS leading to refractory hypoxia, for which Extra Corporeal Membranous Oxygen (ECMO) was started. It had to be weaned off in 4 days because of persistent thrombocytopenia. Rising titer of protective antibody were detected for the first time on day 12 but patient developed huge intracerebral bleed with mass effect, which was not amenable for surgical treatment. He was made comfort care by the family and ultimately died.
DISCUSSION: This case warns the intensivists about the development of Multi Organ Dysfunction during the clinical course of rabies and requirement of multiple sub- specialties in its management. There is no known therapy for rabies and new approaches need to be developed in light of multiple failures of the Milwaukee protocol .
CONCLUSIONS: As one of the oldest and deadliest infectious diseases, rabies is long overdue for development of a successful treatment.
1) Aramburo A, Willoughby RE, Bollen AW, Glaser CA, Hsieh CJ, Davis SL, Martin KW, Roy-Burman A. Failure of the Milwaukee protocol in a child with rabies. Clin Infect Dis. 2011 Sep;53(6):572-4
2) Jackson AC. Rabies in the critical care unit. Can J Neurol Sci. 2011 Sep;38(5):689-95: diagnostic and therapeutic approaches.
DISCLOSURE: The following authors have nothing to disclose: Dilpreet Kaur, Birendra Sah
No Product/Research Disclosure InformationSUNY Upstate Medical University, Syracuse, NY