Fatal Rabies Despite Appropriate Post-exposure Prophylaxis
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《交互式心脏血管和胸部手术医学期刊》
Department of Pediatrics, 7 Air Force Hospital, Nathu Singh Road, Kanpur Cantt. 208 004, India.
The Indian subcontinent accounts for almost half of the deaths worldwide due to rabies encephalitis. The magnitude of problem is compounded by inappropriate post-exposure rabies prophylaxis(1). We describe a case of fatal rabies despite use of purified chick-embryo vaccine (PCEV) and human rabies immunoglobulin (HRIG).
A 5-year-old girl presented to us with a 7 cm laceration with a flap hanging in front of the left eye following a stray dog bite 6 h back. Wound cleansing with povidone iodine and tetanus toxoid administration had been done at a nearby dispensary immediately after the bite. PCEV (Rabipur, Chiron Behring Vaccines Pvt. Ltd.) was given over deltoid region and 20 IU/kg of HRIG (RABGLOB, Bharat Serums & Vaccines Ltd.) was administered (~ 50% infiltrated locally and rest intramuscularly). Laceration was sutured after 24 h because of the high likelihood of a bad scar in the girl child. She was discharged after the 3rd dose of Rabipur on day 7 and received the 4th dose on day 14. On day 17 following the bite, she reported with typical features of aerophobia and hydrophobia. Although the diagnosis of rabies was obvious, variants of Guillain-Barre syndrome and acute disseminated encephalomyelitis were also considered in view of the supervised vaccination profile. Investigations revealed polymorphonuclear leucocytosis in blood and lymphocytic pleocytosis in the CSF. The child rapidly deteriorated with dysauto-nomia, aspiration pneumonia, and seizures and died despite mechanical ventilation over the next 36 hours. Autopsy was positive for Negri bodies and rabies antigen.
Though an estimated 10 million people receive post-exposure treatments each year after being exposed to rabies suspect animals, only sporadic reports of failure of post exposure prophylaxis exist in published literature(2-4). Failure of prophylaxis has often been attributed to non-adherence to the WHO recommendations especially for class III bites(1,4). Given the current dismal status of post-exposure prophylaxis, reported failures in our country are surprisingly uncommon(1).
We encountered a case of failure of rabies prophylaxis despite adherence to WHO recommendations. A short incubation period, failure to infiltrate maximum HRIG locally due to anatomic nonfeasibility and suturing of the wound (even though done after PCEV and HRIG administration) could have been contributory in our case. Immunodepression, chronic disease, surgery under anesthesia, concurrent use of serum and antimalarials, alcoholism and drugs, inhibition of response of vaccine by antisera/immunoglobulin and inability to maintain cold chain for vaccine or immunoglobulin in developing countries have been postulated for failure of rabies prophylaxis(2-5). Therapeutic failures also indicate an urgent need of reassessment of vaccines and sera in terms of their potency at user level(5).
References
1. Chhabra M, Ichhpujani RL, Tewari KN, Lal S. Human rabies in Delhi. Indian J Pediatr. 2004 Mar; 71: 217-220.
2. Hemachudha T, Mitrabhakdi E, Wilde H, Vejabhuti A, Sripataravanit S, Kingnate D.Additional reports of failure to respond to treatment after rabies exposure in Thailand. Clin Infect Dis 1999; 28: 143-144.
3. Arya S C. Therapeutic failures with rabies vaccine and rabies immunoglobulin. Clin Infect Dis 1999; 29: 1605.
4. Fescharek R, Franke V, Samuel M R.Do anaesthetics and surgical stress increase the risk of post-exposure rabies treatment failure Vaccine 1994; 12: 12-13.
5. Dutta J K, Pradhan S C, Dutta T K.Rabies antibody titers in vaccinees: protection, failure and prospects. Int J Clin Pharmcol Ther Toxicol 1992; 30: 107-112.(B.M. John, S.K. Patnaik,)
The Indian subcontinent accounts for almost half of the deaths worldwide due to rabies encephalitis. The magnitude of problem is compounded by inappropriate post-exposure rabies prophylaxis(1). We describe a case of fatal rabies despite use of purified chick-embryo vaccine (PCEV) and human rabies immunoglobulin (HRIG).
A 5-year-old girl presented to us with a 7 cm laceration with a flap hanging in front of the left eye following a stray dog bite 6 h back. Wound cleansing with povidone iodine and tetanus toxoid administration had been done at a nearby dispensary immediately after the bite. PCEV (Rabipur, Chiron Behring Vaccines Pvt. Ltd.) was given over deltoid region and 20 IU/kg of HRIG (RABGLOB, Bharat Serums & Vaccines Ltd.) was administered (~ 50% infiltrated locally and rest intramuscularly). Laceration was sutured after 24 h because of the high likelihood of a bad scar in the girl child. She was discharged after the 3rd dose of Rabipur on day 7 and received the 4th dose on day 14. On day 17 following the bite, she reported with typical features of aerophobia and hydrophobia. Although the diagnosis of rabies was obvious, variants of Guillain-Barre syndrome and acute disseminated encephalomyelitis were also considered in view of the supervised vaccination profile. Investigations revealed polymorphonuclear leucocytosis in blood and lymphocytic pleocytosis in the CSF. The child rapidly deteriorated with dysauto-nomia, aspiration pneumonia, and seizures and died despite mechanical ventilation over the next 36 hours. Autopsy was positive for Negri bodies and rabies antigen.
Though an estimated 10 million people receive post-exposure treatments each year after being exposed to rabies suspect animals, only sporadic reports of failure of post exposure prophylaxis exist in published literature(2-4). Failure of prophylaxis has often been attributed to non-adherence to the WHO recommendations especially for class III bites(1,4). Given the current dismal status of post-exposure prophylaxis, reported failures in our country are surprisingly uncommon(1).
We encountered a case of failure of rabies prophylaxis despite adherence to WHO recommendations. A short incubation period, failure to infiltrate maximum HRIG locally due to anatomic nonfeasibility and suturing of the wound (even though done after PCEV and HRIG administration) could have been contributory in our case. Immunodepression, chronic disease, surgery under anesthesia, concurrent use of serum and antimalarials, alcoholism and drugs, inhibition of response of vaccine by antisera/immunoglobulin and inability to maintain cold chain for vaccine or immunoglobulin in developing countries have been postulated for failure of rabies prophylaxis(2-5). Therapeutic failures also indicate an urgent need of reassessment of vaccines and sera in terms of their potency at user level(5).
References
1. Chhabra M, Ichhpujani RL, Tewari KN, Lal S. Human rabies in Delhi. Indian J Pediatr. 2004 Mar; 71: 217-220.
2. Hemachudha T, Mitrabhakdi E, Wilde H, Vejabhuti A, Sripataravanit S, Kingnate D.Additional reports of failure to respond to treatment after rabies exposure in Thailand. Clin Infect Dis 1999; 28: 143-144.
3. Arya S C. Therapeutic failures with rabies vaccine and rabies immunoglobulin. Clin Infect Dis 1999; 29: 1605.
4. Fescharek R, Franke V, Samuel M R.Do anaesthetics and surgical stress increase the risk of post-exposure rabies treatment failure Vaccine 1994; 12: 12-13.
5. Dutta J K, Pradhan S C, Dutta T K.Rabies antibody titers in vaccinees: protection, failure and prospects. Int J Clin Pharmcol Ther Toxicol 1992; 30: 107-112.(B.M. John, S.K. Patnaik,)