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Rabies in the accident and emergency department
  1. A Mohamed,
  2. A Banerjee
  1. Accident and Emergency Department, Whittington Hospital, Highgate Hill, London N19 5NF

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    Editor,—We wish to report on a patient with rapidly fatal rabies who presented to our accident and emergency department.This is the only reported fatality from this disease in the United Kingdom since 1988.With increasing worldwide travel, rabies has the potential to present to hospitals in the United Kingdom. Awareness of this condition is required, particularly when assessing an unusual illness in a patient who has recently been in a rabies endemic zone.

    An 18 year old Nigerian student, who had returned from Nigeria three weeks previously, attended with sudden onset of difficulty in breathing. This followed three days of malaise and fatigue. He was unable to stand and walk or to get on to the trolley unaided. He had been previously well and was not taking any long term medication. On examination, he appeared anxious and agitated, but not obtunded. Vital sign measurements showed that he was afebrile, normotensive but tachypnoeic. Oxygen saturation was 99% on room air. There was no specific abnormalities on system examination.

    Investigations revealed glycosuria, proteinuria, ketonuria, hyperglycaemia (blood glucose 10.9 mmol/l) and respiratory alkalosis. Blood counts and a haemoglobinopathy screen were normal. A blood smear showed scanty Plasmodium falciparum parasitaemia. Blood culture subsequently grew Neisseria species. Initial differential diagnoses included cerebral malaria and possible substance misuse.

    After admission, however, features of rabies were noted, including drooling of saliva, hydrophobia,and painful generalised spasms. He was subsequently transferred to a regional infectious diseases unit and died shortly after arrival. A postmortem examination confirmed the diagnosis of rabies. All hospital personnel actively involved in his management were offered and accepted rabies immunisation, without any adverse sequelae.

    In this patient, a history of dog bite on the foot was only obtained in retrospect, as it had occurred several months ago. This is often the case with long incubation periods associated with a low dose of inoculum and preliminary infection of the muscles at the site of the bite before spread to peripheral nerves.1

    This patient presented with the commoner furious form of the disease, associated with hyperactivity, bizarre behaviour, hallucinations, aggression, and generalised spasms. There is a less common paralytic variety that presents with acute ascending flaccid paralysis mimicking Guillain-Barre Syndrome. Once a diagnosis is suspected, specialist virological opinion should be sought. Supportive management and barrier nursing should be instituted. Personnel who have been bitten, or licked by the patient on mucosae or open wounds, require post-exposure antirabies prophylaxis. The outlook remains dismal with only four survivors reported in the world literature.

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