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.