Rabies: Difference between revisions
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==Background== | ==Background== | ||
*Indication for | *Almost always fatal (diagnosis frequently made postmortem) | ||
*Indication for prophylaxis: | |||
**Bite or salivary exposure from bat, or mammalian carnivore | **Bite or salivary exposure from bat, or mammalian carnivore | ||
**Close proximity with unknown salivary exposure (e.g. live/dead bat in room) | **Close proximity with unknown salivary exposure (e.g. live/dead bat in room) | ||
Line 6: | Line 7: | ||
==Clinical Features== | ==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 | |||
===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)<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. | |||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
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=====Animal was captured===== | =====Animal was captured===== | ||
''Is animal dog or cat?'' | ''Is animal dog or cat?'' | ||
*Yes: Observe 10 days, if abnormal, | *Yes: Observe 10 days, if abnormal, euthanize and treat patient with the vaccine and RIG. Then patient treatment can be discontinued if the animal pathology is negative for rabies | ||
*No: | *No: Euthanize animal and treat patient with vaccine and RIG. Discontinue if animal pathology is negative for rabies | ||
=====Animal was not captured===== | =====Animal was not captured===== | ||
''Is | ''Is animal dog or cat?'' | ||
*Yes: Give | *Yes: Give vaccine and RIG only if rabies risk for species in area | ||
*No: Treat with | *No: Treat with full course vaccine and RIG | ||
==Management== | ==Management== | ||
===Immunocompetent + NOT Vaccinated=== | ===Prophylaxis=== | ||
====Immunocompetent + NOT Vaccinated==== | |||
*Clean the wound (e.g. copious irrigation) | *Clean the wound (e.g. copious irrigation) | ||
*Rabies vaccine (human diploid cell vaccine) | *Rabies vaccine (human diploid cell vaccine) | ||
Line 31: | Line 46: | ||
**20 IU/kg subcutaneous | **20 IU/kg subcutaneous | ||
**Infiltrate around wound if possible | **Infiltrate around wound if possible | ||
** | **Place remainder opposite arm of vaccine | ||
** | **Can administer up to 7 days after the first vaccine dose | ||
===Immunocompetent + Vaccinated=== | ====Immunocompetent + Vaccinated==== | ||
*Clean the wound | *Clean the wound (e.g. copious irrigation) | ||
*Rabies vaccine (human diploid cell vaccine) | *Rabies vaccine (human diploid cell vaccine) | ||
**1mL IM on days: 0 and 3 | **1mL IM on days: 0 and 3 | ||
Line 41: | Line 56: | ||
*NO rabies immune globulin | *NO rabies immune globulin | ||
===Immuno-compromised=== | ====Immuno-compromised==== | ||
*Clean the wound | *Clean the wound (e.g. copious irrigation) | ||
*Rabies vaccine (human diploid cell vaccine) | *Rabies vaccine (human diploid cell vaccine) | ||
**1mL IM on days: 0, 3, 7, 14, and 28<ref name="4 dose"></ref> | **1mL IM on days: 0, 3, 7, 14, and 28<ref name="4 dose"></ref> | ||
Line 48: | Line 63: | ||
*AND, Rabies immune globulin | *AND, Rabies immune globulin | ||
**20 IU/kg subcutaneous | **20 IU/kg subcutaneous | ||
**Infiltrate around wound if possible | **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== | ==Disposition== | ||
*Patient needing prophylaxis: outpatient | |||
*Clinical rabies: admit | |||
==See Also== | ==See Also== | ||
*[[Mammalian bites]] | |||
==References== | ==References== |
Latest revision as of 15:47, 4 April 2021
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
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
- Acute tetanus
- Akathisia
- Conversion disorder
- Drug toxicity (anticholinergic, phenytoin, valproate, carbamazepine)
- Dystonic reaction
- Electrolyte abnormality
- Hypocalcemic tetany
- Magnesium
- Mandible dislocation
- Meningitis
- Peritonsillar abscess
- Rabies
- Seizure
- Strychnine poisoning
- Stroke
- Temporomandibular disorder
- Torticollis
Evaluation
Algorithm for Prophylaxis
Animal was captured
Is animal dog or cat?
- Yes: Observe 10 days, if abnormal, euthanize and treat patient with the vaccine and RIG. Then patient 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
- ↑ 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).
- ↑ 2.0 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