Case Description
A 33-Year-old male with no chronic illness presented to the emergency
department, Hamad General Hospital, Doha, Qatar, with 2 days history of
fever, sore throat, irritability, and inability to drink water. He came
one month ago from his home country to join a new job. The patient
recalled a history of biting to his right ear by an unknown animal 3
months ago. No medical advice was sought and reported a completely
healed wound. On examination, appeared agitated, febrile with a
temperature of 38.3 C, and stable other vitals. Anxiety was noted when
water was mentioned or seen by the patient. No nuchal rigidity or any
focal neurological signs. Healed scar was noted in the pinna of the
right ear. Blood tests, including, complete blood counts, renal profile,
Liver function test and C-Reactive protein were within the reference
ranges. CT Brain was normal (figure 1). Lumbar puncture showed
lymphocytic CSF with negative bacterial cultures. Intravenous
Ceftriaxone and Acyclovir were started to cover for possibilities of
viral or bacterial encephalitis, but both stopped latter when the CSF
bacterial cultures and viral PCR Panel came negative. Rabies real-time
PCR for CSF and nape of skin biopsy were all negative. There were no
Rabies virus (RABV) neutralizing antibodies detectable in the CSF and
plasma, however, two different real-time PCR assays for RABV on saliva
samples tested positive(6),(7) Immediately on
suspicion of rabies, the patient received rabies vaccine,
rabies
immune globulin and Ribavirin. On day 3, the patient was intubated and
sedated after he had developed hypotension, desaturation, and decreased
level of consciousness. He continued to deteriorate at day 7 with
generalized convulsions and further hypotension despite pressure support
until sustained uncontrolled hypotension on day 10. Brainstem death was
confirmed on day 18 where the family accepted to stop all forms of
treatment including ventilatory support and shortly after succumbed to
the illness.