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Updated: Dec 23 2021


  • Snapshot
    • A 13-year-old boy in rural Asia presents to a local hospital after a dog bite. The dog did not belong to anybody and is often seen running around the area. His parents report that this occurred a few weeks ago, but that they weren’t concerned until the boy started having low-grade fever and chills. While the physician explains that they can administer both active and passive immunity, as symptoms have already started, the parents must prepare for the worst.
  • Introduction
    • Classification
      • rabies virus
        • a negative single-stranded linear RNA virus
        • a rhabdovirus
        • a helical capsid and bullet-shaped
      • transmission
        • via bites from infected animals
          • developed countries
            • bats > raccoons, and skunks > dogs
          • developing countries
            • dogs > others
        • via aerosol transmission (rare)
          • bats
    • Associated conditions
      • encephalitic rabies (more common)
      • paralytic rabies
    • Prevention
      • whole virus inactivated vaccine
        • passive immunization
      • rabies immunoglobulin
        • active immunization
  • Epidemiology
    • Demographics
      • more common in children
      • majority of cases are in Asia and Africa
    • Risk factors
      • interaction with non-domestic animals
    • Pathogenesis
      • long incubation period (weeks to months)
      • replicates in muscle and binds to the nicotinic acetylcholine receptor
        • retrograde migration to central nervous system via dynein motors
  • Presentation
    • Symptoms
      • nonspecific prodrome
        • malaise
        • fever
        • headache
    • Physical exam
      • fever
      • encephalitic rabies
        • hydrophobia
          • muscle spasms when offered water
          • leads to “foaming at the mouth”
        • photophobia
        • autonomic dysfunction
          • excess sweating
          • piloerection
          • hypersalivation
        • agitation
        • seizures
      • paralytic rabies
        • quadriparesis
        • bilateral facial weakness
      • late stage disease
        • paralysis
        • coma
        • death 
  • Studies
    • Labs
      • viral studies
        • reverse transcription and polymerase chain reaction
        • isolation of virus
    • Histology
      • brain biopsy
        • performed post-mortem
        • negri bodies
          • eosinophilic inclusion bodies in cerebellar Purkinje cells and hippocampal neurons
          • pathognomonic
    • Making the diagnosis
      • based on clinical presentation
  • Differential
    • Botulism
      • distinguishing factor
        • flaccid paralysis without other signs of encephalopathy
    • Temporal lobe (herpes simplex virus-1) encephalitis
      • distinguishing factor
        • disinhibited behaviors such as hyperphagia, hypersexuality, and hyperorality
  • Treatment
    • Management approach
      • give post-exposure prophylaxis immediately
        • when bitten by rabid animal
        • when bite cannot be ruled out
        • if the animal is domestic observe the animal for 24-48 hours
      • once patients are symptomatic, there is no treatment and patients should receive supportive care
        • pain management
        • sedation
    • Conservative
      • wound cleaning
        • indication
          • post-exposure
    • Medical
      • post-exposure prophylaxis
        • indication
          • first-line treatment given immediately after potential high-risk exposure and unable to observe animal
        • drug regimen
          • rabies vaccine alone
            • patients who have received a rabies vaccine series in the past
          • rabies vaccine plus rabies immune globulin
            • patients who have not received a rabies vaccine series in the past
  • Complications
    • Respiratory failure leading to death
  • Prognosis
    • Most cases, without early intervention, lead to coma and death within weeks
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