RABIES

By Zakariya Al-nuaimi
 INTRODUCTION

• Rabies is a viral disease that produces an almost uniformly fatal encephalitis in

humans and most other mammals.
• Rabies is one of the oldest and most feared human infections with the highest case
fatality rate of any infectious disease.
• Rabies is a zoonosis infecting a variety of mammal species in different areas of
the world.
• Rabies, Latin for “madness,”
• In English, rabies is also known as ‘hydrophobia’, ‘lyssa’ and ‘mad dog bite’:
 HISTORY

• Rabies in dogs and the importance of saliva in its transmission may have been recognized in
pharaonic times
• Aristotle (322 BC) described rabies in animals but seemed to deny that humans could be
infected or could die from the disease.
• Pasteur adopted the use of rabbits in his studies of rabies beginning in 1880.
• He was the first to recognize that the major site of infection was the central nervous system.
• Pasteur was able to protect dogs from challenge by immunizing them with a virus
attenuated in desiccated rabbit spinal cord
• and in 1885 he used this as a vaccine successfully for the first time in two boys who had
been severely bitten by rabid dogs.
 VIROLOGY

• Rhabdoviridae Family, genus

Lyssavirus
• The Rhabdoviridae are rod-
shaped, negative-sense,
nonsegmented,
single-stranded RNA viruses.

bullet-shaped
 EPIDEMIOLOGY

• HUMAN RABIES
Rabies is currently distributed worldwide except for Antarctica and a few island nations.
• Worldwide, dogs account for 54% of animal rabies, terrestrial wildlife for 42%, and bats for 4%
• The World Health Organization (WHO) estimates that 55,000 humans die of rabies annually.
 PATHOGENESIS

• Rabies infection begins with centripetal spread of

the virus via peripheral nerves to the CNS,
proliferation within the CNS, and centrifugal
spread via peripheral nerves to many tissues.

• Virus is present in dorsal root ganglia within 60 to

72 hours of inoculation and before its arrival in
spinal cord neurons, which confirms its transport
within sensory neurons.
ROUTES OF INFECTION
The following are very unusual routes
of human infection:

A bite with prominent Human-to-human transmission has only been documented in recipients of
salivary contamination (e.g., corneal transplant grafts.
through exposed skin) is
more likely to produce rabies
than a bite through thick Inhalation has been reported from the USA
clothing that removes saliva
from the animal’s teeth.
Vaccine-induced rabies 18 people developed paralytic rabies in Brazil, in 1960.
incomplete inactivation of virus in human vaccine should no longer be a problem

Multiple bites are more likely

to transmit the disease than a Transplacental infection has occurred in animals Several women with rabies
single bite. The location of encephalitis have been delivered of healthy babies.
the bite also influences the

Oral infection has been shown in animals ingestion of milk from an infected
animal. Boiling and pasteurization inactivate rabies virus. in the US people who
had drunk milk from rabid cows were given rabies prophylaxis (Centers for
Disease Control, 1999b)
 CLINICAL MANIFESTATIONS

• The reported incubation period for

rabies varies from a few days to
more than 19 years, although 75%
of patients become ill in the first
90 days after exposure.
 DIAGNOSIS

• Several tests are necessary to diagnose rabies ante-mortem (before death) in humans; no single test is sufficient.
• Tests are performed on samples of saliva, serum, spinal fluid, and skin biopsies of hair follicles at the nape of the
neck.
• Saliva can be tested by virus isolation or reverse transcription followed by polymerase chain reaction (RT-PCR).
• Serum and spinal fluid are tested for antibodies to rabies virus.
• Skin biopsy specimens are examined for rabies antigen in the cutaneous nerves at the base of hair follicles.
• Computed tomographic scan results of the brain are usually normal early in the course,
• Post-mortem CNS biopsies
 Semple-type (grown in sheep brain cultures) human vaccines
cost about $5 per course, Vero cell vaccine in France about $160
per course, and human diploid cell rabies vaccine (HDCV) in
TREATMENT the United States more than $500 per course

• Only one case exists of complete recovery from rabies in a patient who
had not received rabies prophylaxis either before or after illness onset.
• The patient was a 15-year-old girl from Wisconsin who had a bat bite 1 month before symptom onset.
• The patient was placed into electrographic burst suppression with ketamine and midazolam. Antiviral therapy
commenced with ribavirin and amantadine

• The patient was discharged to home on the 76th day after admission with persistent choreoathetosis and ballismus.
• Twenty-seven months after exposure, the patient was taking college courses and attending to her own activities of
daily living, with only mild neurologic deficits
POSTEXPOSURE TREATMENT

• The cornerstone of rabies prevention is wound care, which potentially reduces the risk of rabies by
90%.
• Thorough washing with a 20% soap solution is as effective as the formerly recommended quaternary
ammonium compounds.
• Irrigation with a virucidal agent such as povidone-iodine is advisable.

• After wound care, the clinician must decide whether to institute passive and active immunization
• In countries of low prevalence, a healthy dog or cat that has bitten, or otherwise transferred saliva to,
a human is observed for 10 days.
 Postexposure treatment
should always include
administration of both
passive antibody and
vaccine for both bite and
nonbite exposures in
persons with no previous
vaccination for rabies.
PREVENTION

• PREEXPOSURE PROPHYLAXIS
• Although control of animal rabies is central to prevention of human disease, few nations have
eliminated it.
• Prophylaxis for cats and dogs in many countries is required by law; in the United States, the use of
1-year or 3-year vaccines is permitted, although only the 3-year vaccines are recommended.
• Preexposure prophylaxis is confined to people with a relatively high risk of rabies exposure, such as
veterinarians, laboratory workers who use rabies virus, spelunkers, and people who plan to visit
countries of high dog rabies prevalence where access to appropriate medical care is limited.
REFERENCES

• MANDELL, DOUGLAS, AND BENNETT’S PRINCIPLES AND PRACTICE OF

INFECTIOUS DISEASES Seventh Edition
• Principles and Practice of Clinical Virology FIFTH EDITIONE