This has to reach to the community since it is taken in granting that rabies means death. Hence rarely treatment is tried to make survive. We report another patient with this deadly disease who survived during hospital stays with the help of modified Milwaukee protocol and intensive critical care support. A year-old woman from Bijnor, Uttar Pradesh North-India with no significant past illness, medication history, or travel history presented with 5-days duration of acute onset fever that was high grade, continuous, associated with headache, and nonbilious vomiting.
She had altered sensorium since day 1 of progressive nature and fluctuating course associated with agitation, incomprehensible speech, hydrophobia, and bedwetting. Relatives gave a history of category-3 dog street bite over the left facial area near nose 20 days back and took three doses of postexposure prophylaxis of purified chick embryo cell rabies vaccine on the next day 18 h of bite.
However, she had not received any anti-rabies immunoglobulin. She had local paresthesia symptoms over the left face since then. The dog was killed by villagers to protect themselves from being bitten by a dog but not being examined in the laboratory. On detailed CNS examination, she had normal size right pupil with reaction to light and left side phthisis bulbi from birth. Rest examinations were unremarkable. Considering her demography and clinical presentation, few differentials were considered.
These were rabies encephalitis, herpes meningoencephalitis, tubercular meningoencephalitis, scrub encephalitis, another infective encephalopathy, metabolic encephalopathy, and central nervous system vasculitis. However, rabies is considered the most. The patient's hematological and biochemical parameters were within normal limits.
Screening tests for common infections were negative. Magnetic resonance imaging of brain; a T2W image b FLAIR image showing mild hyperintensities in bilateral basal ganglia arrows without diffusion restriction or hemorrhages on the gradient not shown. The patient was managed in the isolation ward with ventilator support, barrier nursing, and strict standard precautions with modified Milwaukee protocol.
During hospital day HD , 0—7 days: the patient was intubated and kept under sedation with infusions of ketamine 0. Monitoring was going on every hourly; hypocarbia was avoided. CVP line, NG tube, and urinary catheter were placed.
On HD, 7—14 days, we continued supportive therapy, tapered sedation aggressively and stop by day However, we continued low-dose insulin, amantadine, vitamin-C, fludrocortisone, and tapered dexamethasone. On day 15, the patient had GCS — E4VtM1, the patient was on improving trend but her attendant was not ready to stay further despite repeatedly counseling and went to leave against medical advice LAMA on Ambu bag with premature termination of treatment.
She was followed up telephonically, however, she had expired in 12 h after reaching home next day of discharge. We report an old-aged woman who presented in the encephalitic state after 20 days of a street rabid dog bite of category She took incomplete postexposure prophylaxis PEP without rabies immunoglobulins. She was treated on modified Milwaukee protocol and remained to survive for 15 days during the hospital stay but death occurred at home because of premature termination of treatment due to LAMA.
Rabies is a fatal disease accounting at least 60, deaths per year. With the passage of time, few physicians have tried interventions to make them survive. As a result, there have been few well-documented rabies survivors until now [ Table 1 ]. Before , only five cases were survived who received incomplete PEP.
Ideally, PEP should begin immediately after animal bite as soon as the washing of all wounds with soap and water, so that viral load can be reduced at the site of inoculation. The most common causes of failure of PEP are 1 lack of use of rabies immunoglobulin, 2 not all wounds are injected with immunoglobulin, 3 a 6-day delay in the prophylaxis, 4 suturing of wounds before immunoglobulin injection, and 5 wounds in the highly innervated region of the body such as face and hand.
However, after , more cases are being documented to have survival. In , a teenager survived who had not rabies vaccinations pre-exposure or postexposure; active or passive and been treated using an experimental Milwaukee protocol having induced coma and antiviral treatment.
If you see all the survived cases 24 including our case after , all have used aggressive critical care options. Hence, the intensive approach may be modified Milwaukee protocol is the solution to survive rabies. Among the thirty documented survivors including ours , four cases were bitten by bats [ Table 1 ]. Bat associated rabies virus is thought to be less virulent and associated with a good prognosis.
Five survivors did not receive any PEP, six received vaccines as well as immunoglobulins, and all other patients received only vaccines. Hence, other factors like an aggressive treatment approach are to be considered for making survival when the patient is not immunized or even partial immunized. This has to be incorporated into the mind of primary care physicians who frequently deal with rabies patients.
There are good and bad prognostic factors in rabies as reviewed in Table 2. Our case was weaning from ventilation and eye-opening was achieved but she had not shown any limb movements that may show she was in a vegetative state similar to many survived previous cases with the severe sequel.
However, data from the survivors along with those who survive longer before dying can provide data about clinical rabies that can be learned from to develop better therapies.
Reviews published in late and last month list a total of 19 documented survivors from onwards, noting that many had partial or delayed pre- or post-exposure vaccination against rabies prior to symptoms developing. Those with bat-associated rabies and those with robust early immune reactions may also have better survival prospects. Finally, a recent report describes a patient with a history of a bite from a dog infected with rabies who recently survived after only relatively simple hospital treatment in a hospital in Ghana.
This case is one of presumptive rabies, as laboratory diagnosis was not available in this setting, but the symptoms, including hydrophobia and photophobia, were highly characteristic of rabies. In resource poor settings, where rabies is woefully underreported, diagnoses of rabies are rarely confirmed in laboratories, and people clinically diagnosed with rabies are generally sent home to die, is it possible that more, undocumented survivors exist? Caicedo is hopeful, but indicated that Gomez will face a long, slow recovery.
She would not say how long Gomez was comatose but told ScientificAmerican. The child can move her fingers but cannot walk or eat on her own, and her eyes are open but she cannot speak yet and physicians are not sure if she can see, Caicedo says. Giese, informed of the case, says that she "hopes and prays" that Gomez will survive. Giese was the keynote speaker at a conference last week in Atlanta, where scientists gathered to discuss the latest research being conducted on ways to battle the deadly disease.
During her talk, she urged physicians to continue efforts to pin down treatments that work. Giese was 15 when she was infected after being bitten by a rabid bat she had picked up outside her church in her hometown of Fond du Lac, Wisc. Her parents cleaned the superficial wound and she says they did not believe it was necessary to seek further medical treatment.
By the time Giese began displaying signs of rabies three weeks later—fatigue, double vision, vomiting and tingling in her left arm—it was too late for the antirabies vaccine cocktail. Instead of giving her up for dead, the doctors decided to "shut the brain down and wait for the cavalry to come" by inducing a coma to give her own immune system time to build up antibodies against the virus, says Rodney Willoughby , an infectious disease specialist who treated Giese at the Children's Hospital of Wisconsin in Milwaukee.
Willoughby devised the treatment credited with saving Giese there, which has since become known as the Milwaukee protocol. Rabies kills by compromising the brain's ability to regulate breathing, salivation and heartbeat; ultimately, victims drown in their own spit or blood, or cannot breathe because of muscle spasms in their diaphragms. One fifth die from fatal heart arrhythmia. Doctors believed that Giese might survive if they suppressed her brain function by sedating her while her immune system attacked the rabies virus.
This was the first time the therapy was attempted, and doctors had no clue if it would work or, if it did, whether it would leave her brain damaged. But Willoughby says it was the only chance doctors had of saving her. When she arrived at the hospital, Giese couldn't talk, sit or stand and fell in and out of consciousness—she also needed to be intubated to help her breathe.
They tapered off the anesthetics after about a week, when tests showed that Giese's immune system was battling the virus. For about six months after awakening from the coma, physicians also gave her a compound called tetrahydrobiopterin that is chemically similar to the B-complex vitamin folic acid, which may have improved her speech and ability to eat, Willoughby says.
He notes that physicians gave her the supplement after tests showed that she had a deficiency of the compound, which is known to boost production of serotonin and dopamine neurotransmitters needed to perform motor, speech and other routine bodily functions.
Remarkably, Giese survived. She recovered most of her cognitive functions within a few months, and other skills within a year, Willoughby says.
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