Case Presentation:
A 19‐year‐old man presented with 1 day of pain and numbness in his left arm accompanied by left‐sided facial numbness. The patient reported chest pain, neck pain, nausea, and a dry cough as well. He denied fever, chills, night sweats, or headache. The patient was a landscaper who had recently arrived from Mexico. The patient had a temperature of 38.4°C, a heart rate of 110 bpm, respirations of 22 breaths/min, and a blood pressure of 165/119 mm Hg. He appeared uncomfortable and dyspneic, with generalized diaphoresis and facial erythema. He had left‐sided ptosis, with scleral injection. He had decreased strength bilaterally in his upper extremities. His reflexes were decreased in the upper and lower extremities. He was tachycardic and had clear lungs bilaterally. Laboratory studies revealed a white blood cell count (WBC) of 11.9 × 103/μL. Blood cultures were nondiagnostic. Lumbar puncture revealed glucose of 83 mg/dL, protein of 118 mg/dL, red blood cell count of 18/μL, and WBC of 8/μL, with a lymphocytic predominance. The cerebrospinal fluid cultures were negative for bacteria, HIV, syphilis, herpes, arboviruses, and oligoclonal bands. An MRI of the head revealed diffuse symmetric encephalitis. His condition worsened, and he developed ascending paralysis requiring mechanical ventilation. A repeat lumbar puncture revealed a WBC to 87/μL, with lymphocyte predominance. He progressed to brain death and died after extubation. Postmortem analysis revealed marked cerebral softening, congestion, and edema most consistent with rabies.
Discussion:
Rabies is transmitted from rabid animals. In developing countries, a dog bite is usually the source of inoculation. Following an incubation period of 3–6 months, a prodrome occurs in which patients report nonspecific flulike symptoms for no more than a week. Once the prodrome is complete, the patient enters 1 of 3 symptom paths: (1) encephalitic—hydrophobia, aerophobia, pharyngeal spasms, and hyperactivity; (2) paralytic—quadraparesis with sphincter involvement; and (3) atypical— neuropathic pain, sensory and motor deficits, cranial nerve palsies, and brain stem signs. Rabies is fatal once symptomatic. The key to treatment is early evidence‐based clinical diagnosis. Exposed patients are treated with both immunoglobulin and vaccination. Rabid animals manifest marked behavioral changes, becoming overly friendly, aggressive, or fearless. Subsequently, the animal becomes extremely excitable, restless, and aggressive, with increased salivation, before progressing to the fatal “paralytic stage.” Animal control should be contacted immediately regarding any potentially rabid animal. Individuals should be evaluated for possible exposure and potential treatment if there was any contact with the animal.
Conclusions:
The internist rarely deals with animal bites. However, it is important to know the presentation of rabies. The internist should know how to proceed in cases of bites from suspicious animals, as there are few other diseases that have a treatment window as silent and important as rabies.
Disclosures:
R. Quevedo ‐ none; J. Bhutto ‐ none