Chest Infections |

Looking Beyond the Milwaukee Protocol FREE TO VIEW

Amritpal Nat, MD; Amitpal Nat, MD; Amit Sharma, MD; Aravind Pothineni, MD; Ioana Amzuta, MD
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Suny Upstate Medical University, Liverpool, NY

Chest. 2014;145(3_MeetingAbstracts):117A. doi:10.1378/chest.1826454
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SESSION TITLE: Infectious Disease Case Report Posters I

SESSION TYPE: Case Report Poster

PRESENTED ON: Sunday, March 23, 2014 at 01:15 PM - 02:15 PM

INTRODUCTION: The Milwaukee Protocol was used for a 24 year-old male U.S. soldier who was diagnosed with rabies after being bit by a feral dog in Afghanistan. He did not receive effective post exposure prophylaxis (PEP) for rabies however [1].

CASE PRESENTATION: The diagnosis of rabies was ultimately confirmed as viral antigens and viral RNA were detected on a nuchal skin biopsy and in saliva, csf, and the cornea respectively. Immediately, we initiated the Milwaukee Protocol [2]. 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 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on day-13 of the hospital course, our patient developed an inoperable intra-cerebral hemorrhage and care was withdrawn in the setting of a poor prognosis.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. Survival has occurred in patients with rabies however the majority had received PEP prior to development of symptoms. The Milwaukee Protocol to date has been successful in one patient who developed rabies and did not receive PEP. It involves a therapeutic coma, antiviral therapy, anticipation of known complications, cerebral vasospasm management and avoidance of immunization. Although the positive outcome in that case has been attributed to the treatment regimen, anti-rabies virus antibodies were detected at the time of hospital admission. Given that she was never vaccinated, this more likely reflected the patient's own brisk immune response [1]. Subsequent case reports including ours have demonstrated the failure of the Milwaukee Protocol.

CONCLUSIONS: Our case highlights the first time ECMO was used in rabies. Also, it exemplifies another failed case of the Milwaukee Protocol. Given the lack of efficacy, the protocol should not be used for rabies. A better understanding of rabies pathogenesis is needed in order to develop novel therapies.

Reference #1: Jackson AC. Current and future approaches to the therapy of human rabies. Antiviral Res. 2013 Jul;99(1):61-7.

Reference #2: Willoughby,R et. Al Survival after Treatment of Rabies with Induction of Coma, N Engl J Med2005; 352:2508-2514

DISCLOSURE: The following authors have nothing to disclose: Amritpal Nat, Amitpal Nat, Amit Sharma, Aravind Pothineni, Ioana Amzuta

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