Rabies: Difference between revisions

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Indication for Prophylaxis
==Background==
* Bite or salivary exposure from bat, or mammalian carnivore
*Almost always fatal (diagnosis frequently made postmortem)
* Inhalation counts (e.g. dead bat in room)
*Indication for prophylaxis:
**Bite or salivary exposure from bat, or mammalian carnivore
**Close proximity with unknown salivary exposure (e.g. live/dead bat in room)
*Prophylaxis not needed if non-salivary exposure, or if bird, reptile, or rodent (rare cases)


^Not needed if non-salivary exposure, or if bird, reptile, or rodent (rare cases)
==Clinical Features==
[[File:Manwithrabies4.png|thumb|Man with rabies.]]
''Clinical rabies is incredibly rare.''
*Incubation period = ~20-90 days, but may be shorter or longer


^Call CDC if questions
===Encephalitic form===
*Hyperexcitability, disorientation, bizarre behavior, [[hallucinations]]
*Autonomic dysfunction (e.g. hypersalivation)


===Workup===  
===Paralytic form===
Was animal captured?
*Paresis in bitten extremity → quadriparesis, bilateral facial weakness → coma, organ failure
*Hydrophobia (50%) --> spasms of larynx, pharynx, diaphragm
*Aerophobia (9%) --> spasms of larynx, pharynx, diaphragm in response to drafts of air (pathognomonic)<ref>Petersen BW, Rupprecht CE. Human Rabies Epidemiology and Diagnosis. US Centers for Disease Control and Prevention, 2011. https://www.intechopen.com/books/non-flavivirus-encephalitis/human-rabies-epidemiology-and-diagnosis (Accessed on January 15, 2021).</ref>
*Death from various complications: pituitary complications, respiratory dysfunction, cardiac dysfunction, autonomic dysfunction.


#Yes
==Differential Diagnosis==
##Is animal dog or cat?
{{Jaw spasms DDX}}
###Yes: Observe 10 days, if abnormal, sacrifice and treat with vacc and RIG
####discontinue if animal negative path for rabies
###No: Sacrifice animal and begin RIG and vaccine
####discontinue if animal negative path for rabies
#No
##Is Animal dog or cat?
###Yes: Give vacc and RIG only if rabies risk for species in area
###No: Treat with  full course vacc and RIG


==Treatment==
==Evaluation==
# Clean wound
===Algorithm for Prophylaxis===
# Rabies vaccine: human diploid cell vaccine (HDCV): 1ml IM* Day 0, 3, 7, 14,and 28
=====Animal was captured=====
## Give in deltoid not buttock (since Ab not created in fat cells)
''Is animal dog or cat?''
## If previously immunized: HDCV on day 0, 3; no RIG                 
*Yes: Observe 10 days, if abnormal, euthanize animal and treat patient with the vaccine and RIG. Treatment can be discontinued if the animal pathology is negative for rabies
# RIG (rabies immune globulin): 20 IU/kg (infiltrated SC around wound) if possible
*No: Euthanize animal and treat patient with vaccine and RIG. Discontinue if animal pathology is negative for rabies
##place remainder opposite arm of vaccine
 
##can administer up to 7 days after the first vaccine dose
=====Animal was not captured=====
''Is animal dog or cat?''
*Yes: Give vaccine and RIG only if rabies risk for species in area
*No: Treat with full course vaccine and RIG
 
==Management==
===Prophylaxis===
====Immunocompetent + NOT Vaccinated====
*Clean the wound (e.g. copious irrigation)
*Rabies vaccine (human diploid cell vaccine)
**1mL IM on days: 0, 3, 7, 14<ref name="4 dose">Use of a Reduced (4-Dose) Vaccine Schedule for Postexposure Prophylaxis to Prevent Human Rabies. http://www.cdc.gov/rabies/resources/acip_recommendations.html</ref>
**Give in deltoid (not buttock), since Ab not created in fat cells
*AND, Rabies immune globulin
**20 IU/kg subcutaneous
**Infiltrate around wound if possible
**Place remainder opposite arm of vaccine
**Can administer up to 7 days after the first vaccine dose
 
====Immunocompetent + Vaccinated====
*Clean the wound (e.g. copious irrigation)
*Rabies vaccine (human diploid cell vaccine)
**1mL IM on days: 0 and 3
**Give in deltoid (not buttock), since Ab not created in fat cells
*NO rabies immune globulin
 
====Immuno-compromised====
*Clean the wound (e.g. copious irrigation)
*Rabies vaccine (human diploid cell vaccine)
**1mL IM on days: 0, 3, 7, 14, and 28<ref name="4 dose"></ref>
**Give in deltoid (not buttock), since Ab not created in fat cells
*AND, Rabies immune globulin
**20 IU/kg subcutaneous
**Infiltrate around wound if possible, except for digits and the penis
**Place remainder opposite arm of vaccine
**Can administer up to 7 days after the first vaccine dose
 
==Disposition==
*Patient needing prophylaxis: outpatient
*Clinical rabies: admit
 
==See Also==
*[[Mammalian bites]]
 
==References==
<references/>


[[Category:ID]]
[[Category:ID]]

Latest revision as of 10:00, 4 February 2025

Background

  • Almost always fatal (diagnosis frequently made postmortem)
  • Indication for prophylaxis:
    • Bite or salivary exposure from bat, or mammalian carnivore
    • Close proximity with unknown salivary exposure (e.g. live/dead bat in room)
  • Prophylaxis not needed if non-salivary exposure, or if bird, reptile, or rodent (rare cases)

Clinical Features

Man with rabies.

Clinical rabies is incredibly rare.

  • Incubation period = ~20-90 days, but may be shorter or longer

Encephalitic form

  • Hyperexcitability, disorientation, bizarre behavior, hallucinations
  • Autonomic dysfunction (e.g. hypersalivation)

Paralytic form

  • Paresis in bitten extremity → quadriparesis, bilateral facial weakness → coma, organ failure
  • Hydrophobia (50%) --> spasms of larynx, pharynx, diaphragm
  • Aerophobia (9%) --> spasms of larynx, pharynx, diaphragm in response to drafts of air (pathognomonic)[1]
  • Death from various complications: pituitary complications, respiratory dysfunction, cardiac dysfunction, autonomic dysfunction.

Differential Diagnosis

Jaw Spasms

Evaluation

Algorithm for Prophylaxis

Animal was captured

Is animal dog or cat?

  • Yes: Observe 10 days, if abnormal, euthanize animal and treat patient with the vaccine and RIG. Treatment can be discontinued if the animal pathology is negative for rabies
  • No: Euthanize animal and treat patient with vaccine and RIG. Discontinue if animal pathology is negative for rabies
Animal was not captured

Is animal dog or cat?

  • Yes: Give vaccine and RIG only if rabies risk for species in area
  • No: Treat with full course vaccine and RIG

Management

Prophylaxis

Immunocompetent + NOT Vaccinated

  • Clean the wound (e.g. copious irrigation)
  • Rabies vaccine (human diploid cell vaccine)
    • 1mL IM on days: 0, 3, 7, 14[2]
    • Give in deltoid (not buttock), since Ab not created in fat cells
  • AND, Rabies immune globulin
    • 20 IU/kg subcutaneous
    • Infiltrate around wound if possible
    • Place remainder opposite arm of vaccine
    • Can administer up to 7 days after the first vaccine dose

Immunocompetent + Vaccinated

  • Clean the wound (e.g. copious irrigation)
  • Rabies vaccine (human diploid cell vaccine)
    • 1mL IM on days: 0 and 3
    • Give in deltoid (not buttock), since Ab not created in fat cells
  • NO rabies immune globulin

Immuno-compromised

  • Clean the wound (e.g. copious irrigation)
  • Rabies vaccine (human diploid cell vaccine)
    • 1mL IM on days: 0, 3, 7, 14, and 28[2]
    • Give in deltoid (not buttock), since Ab not created in fat cells
  • AND, Rabies immune globulin
    • 20 IU/kg subcutaneous
    • Infiltrate around wound if possible, except for digits and the penis
    • Place remainder opposite arm of vaccine
    • Can administer up to 7 days after the first vaccine dose

Disposition

  • Patient needing prophylaxis: outpatient
  • Clinical rabies: admit

See Also

References

  1. ↑ Petersen BW, Rupprecht CE. Human Rabies Epidemiology and Diagnosis. US Centers for Disease Control and Prevention, 2011. https://www.intechopen.com/books/non-flavivirus-encephalitis/human-rabies-epidemiology-and-diagnosis (Accessed on January 15, 2021).
  2. ↑ 2.0 2.1 Use of a Reduced (4-Dose) Vaccine Schedule for Postexposure Prophylaxis to Prevent Human Rabies. http://www.cdc.gov/rabies/resources/acip_recommendations.html
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