Epidemiologic Notes and Reports Human Rabies -- Rwanda
On May 7, 1981, a 29-year-old American woman living in Kigali,
Rwanda, was bitten several times on the right foot and probably the
left hand by a dog that later escaped. The patient immediately
sought
medical attention. Her wounds were sutured, and the first dose of
human diploid cell vaccine was given intramuscularly later that
morning (day 0) and on days 3, 7, and 14. No human rabies globulin
was given at that time. Twenty-two days later, she had fever and
paresthesias of the left arm and rapidly became lethargic with
paresis
of arms and legs, dysarthria, and bilaterial facial paresis. She
was
flown to a Belgian hospital 26 days after the bites, where she was
treated intramuscularly with 20 International Units (IU) of human
rabies immune globulin/kg body weight. She rapidly developed a
flaccid quadraplegia and coma, and died 62 days after being bitten.
Immunofluorescence and isolation studies for rabies virus were
negative; however, rabies antibody titer was 827 IU/ml in the
serum,
and 82 IU/ml in the cerebrospinal fluid (CSF). No previous
exposure
to another animal was reported.
Reported by J Devriendt, MD, M Staroukine, MD, Hospital
Universitaire
Brugmann, Brussels, Belgium; Viral Diseases Div, Center for
Infectious
Diseases, CDC.
Editorial Note
Editorial Note: Rabies antibody, especially in such high titers,
has
not been reported in the CSF of persons who have received only
rabies
vaccine. However, high titers of rabies antibody do occur with
clinical rabies, and such high CSF antibody levels are commonly
accepted as diagnostic for rabies. Therefore, the diagnosis of
rabies
is most probable for this patient. Despite the prompt and correct
use
of the human diploid cell rabies vaccine, human rabies immune
globulin
was omitted from this patient's initial post-exposure prophylactic
regimen, and may be related to the failure of treatment. Studies
have
shown that the combination of human rabies immune globulin plus
vaccine is better than either alone in preventing rabies (1,2),
presumably because globulin provides passive antibody protection
during the period when vaccine has not yet induced active antibody
protection.
This episode, by demonstrating that even the new, highly potent
human diploid cell vaccine cannot by itself prevent rabies,
reinforces
the need for human rabies immune globulin for all persons receiving
post-exposure rabies prophylaxis who have not had prior rabies
vaccination.
References
Boltazard M, Bahmanyar M, Ghodssi M, Sabeti A, Gajdusek C,
Rouzebbi E. Practical trail of antirabies serum in those
bitten
by rabid wolves. Bull WHO 1955;13:747-72.
Selimov M, Boltucij L, Semenova E, Kobrinskij G, Zmusko L.
Anwendung des Anti-Rabies Gama-Globulins bei Menschen, die von
tollwutigen Wolfen oder anderen Tieren schwer gebissen wurden.
J
of Hygiene, Epidemiology, Microbiology, and Immunology
1959;3:168-80.
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