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 Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 9  |  Issue : 3  |  Page : 260-263

Feral dog bite causing paralytic rabies: Difficult diagnosis and failure of prevention


1 Department of Neurology, King Abdulaziz Medical City, King Saud bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
2 King Abdullah International Medical Research Center, King Saud bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
3 Department of Medicine, Aseer Central Hospital, Abha, Saudi Arabia
4 Department of Medicine, Aseer Central Hospital, Abha, Saudi Arabia; Department of Neurology, Faculty of Medicine, Kasr Al Ainy Hospital, Cairo University, Cairo, Egypt
5 College of Medicine, King Khalid University, Abha, Saudi Arabia

Date of Submission11-May-2020
Date of Decision22-Jul-2020
Date of Acceptance23-Aug-2020
Date of Web Publication07-Nov-2020

Correspondence Address:
Hussein Algahtani
Department of Neurology, King Abdulaziz Medical City, King Saud bin Abdulaziz University for Health Sciences, P.O. Box: 12723, Jeddah 21483
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/sjhs.sjhs_106_20

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  Abstract 


Rabies is an acute encephalitis caused by a virus from the genus Lyssavirus (family Rhabdoviridae). It has the highest case fatality rate when compared with other infectious diseases, with over 99% of human deaths occurring in Asia and Africa. Animal-related injuries in Saudi Arabia remain a public health problem, with feral dogs accounting for the majority of bites to humans. Eradication of rabies is not achieved yet, and efforts from different parties including the Ministry of Health, the Ministry of Municipal and Rural Affairs, the Saudi Wildlife Commission, and the Preventive Medicine Department should be coordinated. Training courses for emergency physicians and campaigns to educate the general population about animal-related injuries should be conducted. In this article, we report a case of feral dog bite causing paralytic rabies in a Saudi patient. Our case is unique since the cause of death in this patient was lack of family assistance and proper follow-up of the patient to ensure completing the vaccination schedule rather than lack of treatment and resources. The involvement of infection control department should be from the 1st day of dog bite.

Keywords: Dogs, immunization, postexposure prophylaxis, rabies, Saudi Arabia


How to cite this article:
Algahtani H, Shirah B, Chtourou E, Abuhawi O, Abdelghaffar N, Alshehri M. Feral dog bite causing paralytic rabies: Difficult diagnosis and failure of prevention. Saudi J Health Sci 2020;9:260-3

How to cite this URL:
Algahtani H, Shirah B, Chtourou E, Abuhawi O, Abdelghaffar N, Alshehri M. Feral dog bite causing paralytic rabies: Difficult diagnosis and failure of prevention. Saudi J Health Sci [serial online] 2020 [cited 2021 Jan 20];9:260-3. Available from: https://www.saudijhealthsci.org/text.asp?2020/9/3/260/300285




  Introduction Top


Rabies is an acute encephalitis caused by a virus from the genus Lyssavirus (family Rhabdoviridae).[1] It is one of the oldest known diseases in history, with cases dating back to more than 4000 years ago.[2] It has the highest case fatality rate when compared with other infectious diseases, with over 99% of human deaths occurring in Asia and Africa. Rabies kills up to 59,000 people per year worldwide.[3] The disease is usually transmitted from infected animals with an average incubation period of 15 and 90 days in human.[4] Once the clinical signs of the disease develop, death is almost always inevitable.[5] Prevention of clinical rabies is possible after exposure through postexposure prophylaxis (PEP).[6] In this article, we report a case of feral dog bite causing paralytic rabies in a Saudi patient.


  Case Report Top


A 53-year-old male presented to the emergency department after being bitten by a feral dog (Grade 3 bite) on the dorsum of his right hand after 5 h from the insult [Figure 1]. He received skin care and was vaccinated with tetanus vaccine and the first dose of rabies vaccine at 1 ml injection in his deltoid muscle. Although he was instructed to come back on days 3, 7, and 14 to receive the remaining injections of rabies vaccine, he never showed up to continue the scheduled vaccinations. In addition, he was not given the human hyperimmune rabies immunoglobulin. The feral dog was not captured or observed. Three weeks later, he was admitted to the hospital with fever, headache, and agitation. On examination, he was febrile at 38.9°C and tachycardic (110 beats/min) with normal blood pressure, respiratory rate, and oxygen saturation. He was agitated, hyperexcited, restless, and disoriented. No lateralizing neurological signs were observed. Systemic examination was normal. His laboratory investigations showed normal hemoglobin, platelets, renal function tests, and liver enzymes. In addition, he had normal electrolytes and coagulation profile. A cerebrospinal fluid analysis revealed a lymphocytic pleocytosis of 120 cell/mm3 with high protein and normal glucose concentration. Computerized tomography scan of the brain was normal, and the patient was started on ceftriaxone (2 g twice daily), vancomycin (1 g twice daily), and acyclovir (10 mg/kg every 8 h). In addition, he was started on dexamethasone intravenously. Unfortunately, the patient's level of consciousness deteriorated further, and he was intubated and mechanically ventilated 2 days after admission. Polymerase chain reaction (PCR) of cerebrospinal fluid for viral pathogens was negative. His saliva was sent for rabies PCR with a nonconclusive result. Magnetic resonance imaging of the brain was done, which showed classical changes of rabies encephalitis [Figure 2]. Unfortunately, the patient lost his brainstem reflexes a few days later and died 20 days after admission to the hospital.
Figure 1: The dorsum of the right hand of the patient showing the dog bite

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Figure 2: Magnetic resonance imaging of the brain showing classical changes of rabies encephalitis

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  Discussion Top


Rabies is considered one of the most feared zoonotic diseases due to its grave consequences. In the past, a bite from a rabid animal was typically fatal, and people would commit suicide after being bitten by a potentially rabid animal.[7] Since the discovery of Pasteur's rabies vaccine in 1885, there have been a few cases of death due to rabies in the developed countries annually. The developing countries, unfortunately, have a much higher mortality rate.[8]

Rabies is a bullet-shaped virus composed of two parts that cause the disease, the envelope (the structural part) and ribonucleocapsid cone (the functional part).[9] Infection in humans usually occurs through the bite of an infected mammal (domestic and wild) including dogs, raccoons, skunks, foxes, rats, and bats. The routes of infection include skin and mucous membranes (saliva), inhalation of the virus from an aerosolized form, transplacental transmission, and through organ transplants (rare). The speed at which the virus reaches the central nervous system (CNS) depends on the virulence of the strain, the size of the inoculum, the immune status of the host, and the proximity to the brain.[10]

Following a dog bite, the virus infects damaged muscle cells in proximity to the site of infection. They start to replicate without being identified by the host immune cells. The virus then binds to the nicotinic receptors and travels through axons of the nerve cells to reach the dorsal root ganglia of the spinal cord. This mechanism is named retrograde transport. From there, this virus travels rapidly to the CNS and eventually reaches the brain (causing encephalitis) and the spinal cord (causing transverse myelitis). Following brain infection, the virus travels to the cranial nerves and autonomic nervous system. Infection of the salivary glands will transmit the infection to another host.[11]

The initial symptoms of rabies include tingling and numbness at the bite site, fever, sore throat, myalgia, and insomnia.[12] These symptoms are followed days to weeks later by symptoms of encephalopathy including anxiety, confusion, agitation, disorientation, and shortness of breath. In addition, patients develop hydrophobia and aerophobia due to the involvement of the brainstem with neuronal dysfunction around the nucleus ambiguous. This results in inhibition of respiratory muscles as a protective mechanism with subsequent spasms of laryngeal and pharyngeal muscles. Autonomic instability is also seen in around 25% with hypersalivation, sweating, lacrimation, hyperpyrexia, and cardiac arrhythmia. As the disease progresses, the infection evolves into one of the two major forms including encephalitic “furious” rabies representing 80% of cases, or paralytic “dumb” rabies, which represents the remaining 20% of cases. The occurrence of symptoms and signs of encephalitis indicates a poor prognosis, and death usually follows within a few days.[13]

Rabies is one of the reportable infectious diseases in Saudi Arabia, and hospitals and other health-care facilities are obligated to report suspected or confirmed human cases to public health directorate. Three National Reference Laboratories have been assigned to test suspected rabid animals for rabies, which are based in Qassim, Al-Hassa, and Jeddah. Despite the huge advance in health care in Saudi Arabia, the largest country in the Peninsula, little has been published about the rabies situation in the country. While performing a literature review using PubMed, only six papers were published and one case report of confirmed rabies.[14],[15],[16],[17],[18],[19] The patient was bitten by a dog when visiting Morocco.

Although the data are scant, animal-related injuries remain a public health problem. The majority of bites to humans are due to feral dogs, cats, mice, bats, camels, foxes, monkeys, and wolves.[20] In a study done by Kasem et al.[16] using a direct fluorescent antibody test to examine 199 animals suspected of rabies, 79.4% of cases were positive. Dogs, camels, sheep, and goats were the main reservoir. Rabies is not endemic in animals in the United Arab Emirates, Kuwait, and Qatar, and these countries are considered rabies free.[21] This might not be true and could be explained by underreporting, lack of research and publication in these countries, and, finally, a lack of assigned reference laboratories to treat suspected rabid animals for rabies.

Human rabies is a preventable condition if the exposure is recognized, appropriate wound care is provided, and PEP is given. This should be started immediately after the animal bite or exposure and before the occurrence of signs and symptoms of rabies. PEP schedule is administered through the infiltration of 50% of the dose at the site of exposure, with the other half being administered in the deltoid muscle. In children, the anterolateral thigh is used instead of the deltoid muscle. In addition, active immunization is administered on days 0, 3, 7, 14, and 28. When applied appropriately, the combination of active and passive immunization has been very effective in reducing mortality after exposure.[22] Travelers to countries with high risk for rabies exposure are advised to avoid contact with animals. In addition, rabies preexposure prophylaxis is recommended for travelers planning to stay 30 days or more in places with no access to medical care.[23]

Success stories of the elimination of rabies in countries such as Japan, New Zealand, Serbia, Croatia, and Hawaii leave experts that the same fate can be achieved in Saudi Arabia. For travelers to Saudi Arabia, the Centers for Disease Control and Prevention does not recommend routine vaccination against rabies, and only special groups should receive the vaccine. Those include children vulnerable to an animal bite, people at risk, such as in adventure travel and caving, people working with animals, and people taking long trips in remote areas in Saudi Arabia.[24]


  Conclusion Top


Animal-related injuries in Saudi Arabia remain a public health problem with feral dogs accounting for the majority of bites to humans. Eradication of rabies is not achieved yet, and efforts from different parties including the Ministry of Health, the Ministry of Municipal and Rural Affairs, the Saudi Wildlife Commission, and the Preventive Medicine Department should be coordinated. Training courses for emergency physicians and campaigns to educate the general population about animal-related injuries should be conducted. Our case is unique since the cause of death in this patient was lack of family assistance and proper follow-up of the patient to ensure completing the vaccination schedule rather than lack of treatment and resources. The involvement of infection control department should be from the 1st day of dog bite.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Marston DA, Banyard AC, McElhinney LM, Freuling CM, Finke S, de Lamballerie X, et al. The lyssavirus host-specificity conundrum-rabies virus-the exception not the rule. Curr Opin Virol 2018;28:68-73.  Back to cited text no. 1
    
2.
Taylor LH, Nel LH. Global epidemiology of canine rabies: Past, present, and future prospects. Vet Med (Auckl) 2015;6:361-71.  Back to cited text no. 2
    
3.
Hampson K, Coudeville L, Lembo T, Sambo M, Kieffer A, Attlan M, et al. Estimating the global burden of endemic canine rabies. PLoS Negl Trop Dis 2015;9:e0003709.  Back to cited text no. 3
    
4.
Singh R, Singh KP, Cherian S, Saminathan M, Kapoor S, Manjunatha Reddy GB, et al. Rabies-epidemiology, pathogenesis, public health concerns and advances in diagnosis and control: A comprehensive review. Vet Q 2017;37:212-51.  Back to cited text no. 4
    
5.
Fooks AR, Banyard AC, Horton DL, Johnson N, McElhinney LM, Jackson AC. Current status of rabies and prospects for elimination. Lancet 2014;384:1389-99.  Back to cited text no. 5
    
6.
Warrell MJ. Current rabies vaccines and prophylaxis schedules: Preventing rabies before and after exposure. Travel Med Infect Dis 2012;10:1-5.  Back to cited text no. 6
    
7.
Velasco-Villa A, Mauldin MR, Shi M, Escobar LE, Gallardo-Romero NF, Damon I, et al. The history of rabies in the Western Hemisphere. Antiviral Res 2017;146:221-32.  Back to cited text no. 7
    
8.
Lankester F, Hampson K, Lembo T, Palmer G, Taylor L, Cleaveland S. Infectious disease. Implementing Pasteur's vision for rabies elimination. Science 2014;345:1562-4.  Back to cited text no. 8
    
9.
Deviatkin AA, Lukashev AN. Recombination in the rabies virus and other lyssaviruses. Infect Genet Evol 2018;60:97-102.  Back to cited text no. 9
    
10.
Hemachudha T, Ugolini G, Wacharapluesadee S, Sungkarat W, Shuangshoti S, Laothamatas J. Human rabies: Neuropathogenesis, diagnosis, and management. Lancet Neurol 2013;12:498-513.  Back to cited text no. 10
    
11.
Farahtaj F, Alizadeh L, Gholami A, Tahamtan A, Shirian S, Fazeli M, et al. Natural infection with rabies virus: A histopathological and immunohistochemical study of human brains. Osong Public Health Res Perspect 2019;10:6-11.  Back to cited text no. 11
    
12.
El-Sayed A. Advances in rabies prophylaxis and treatment with emphasis on immunoresponse mechanisms. Int J Vet Sci Med 2018;6:8-15.  Back to cited text no. 12
    
13.
Warrell MJ, Warrell DA. Rabies: The clinical features, management and prevention of the classic zoonosis. Clin Med (Lond) 2015;15:78-81.  Back to cited text no. 13
    
14.
Alknawy M, Mohammed I, Ulla SN, Aboud AA. First confirmed case of human rabies in Saudi Arabia. IDCases 2018;12:29-31.  Back to cited text no. 14
    
15.
Memish ZA, Assiri AM, Gautret P. Rabies in Saudi Arabia: A need for epidemiological data. Int J Infect Dis 2015;34:99-101.  Back to cited text no. 15
    
16.
Kasem S, Hussein R, Al-Doweriej A, Qasim I, Abu-Obeida A, Almulhim I, et al. Rabies among animals in Saudi Arabia. J Infect Public Health 2019;12:445-7.  Back to cited text no. 16
    
17.
Dubaib MA. Rabies in camels at Qassim region of central Saudi Arabia. J Camel Pract Res 2007;14:101-3.  Back to cited text no. 17
    
18.
Mishra N, Fagbo SF, Alagaili AN, Nitido A, Williams SH, Ng J, et al. A viral metagenomic survey identifies known and novel mammalian viruses in bats from Saudi Arabia. PLoS One 2019;14:e0214227.  Back to cited text no. 18
    
19.
Sriwijitalai W, Wiwanitkit V. Rabies, rabies vaccine, and renal failure: Clinical issues. Saudi J Kidney Dis Transpl 2019;30:560-3.  Back to cited text no. 19
[PUBMED]  [Full text]  
20.
Fisher CR, Streicker DG, Schnell MJ. The spread and evolution of rabies virus: Conquering new frontiers. Nat Rev Microbiol 2018;16:241-55.  Back to cited text no. 20
    
21.
World Health Organization. WHO Expert Consultation on Rabies-Second Report and Technical Report Series 982. Geneva: World Health Organization; 2013.  Back to cited text no. 21
    
22.
Andrade BF, Andrade TS, Queiroz LH. Human rabies post-exposure prophylaxis relative to the disease epidemiological status. Cien Saude Colet 2019;24:315-22.  Back to cited text no. 22
    
23.
Wallace RM, Undurraga EA, Blanton JD, Cleaton J, Franka R. Elimination of dog-mediated human rabies deaths by 2030: Needs assessment and alternatives for progress based on dog vaccination. Front Vet Sci 2017;4:9.  Back to cited text no. 23
    
24.
CDC-Travelers_ Preexposure Vaccinations – Rabies; 2019. Available from: http://www.cdc.gov/rabies/specific_groups/travelers/pre-exposure_vaccinations.html. [Last accessed on 2019 Dec 27].  Back to cited text no. 24
    


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