Rabies

Question 1

Transmission routes of rabies virus

Answer 1

Saliva, organ transplant, rarely via aerosolidation in lab workers and cavers

Question 2

Post-exposure measures post possible rabies contact

Answer 2

Wound care is crucial, depending on risk category vaccine or HRIG should be offered

Question 3

How is HRIG administered? What is the dose? When would you not use it even if indicated?

Answer 3

Inflitrated intramuscularly around the wound site (any excess in thigh) - not at the same site as vaccine

Dose = 20 IU/kg

Should not be given after 7 days of first PEP vaccine

Question 4

Risk category and rabies PEP for

a) a bat in the room of a sleeping person in UK/Ireland

b) Non-immunised person found with a bat in their room whilst sleeping outside the UK/Ireland OR possible bat contact in UK from unreliable historian OR scratched by a dog from Romania

c) dog bite in India - fully immunised

d) dog bite in India - non-immunised

e) dog bite in India - immunosuppressed

Answer 4

a) Green - None

b) Amber - 4 doses of vaccine (d0, d3, d7, d21)

c) Red - 2 doses of vaccine (d0, d3-7)

d) Red - HRIG and 4 doses of vaccine (d0, d3, d7, d21)

e) Red - HRIG and 5 doses of vaccine (d0, d3, d7, d14, d30)

Question 5

Treatment for rabies (once symptomatic)?

Answer 5

None

Milwalke protocol has been used successfully in a few cases but data is lacking on whether this really works - induced coma, no vaccine or HRIG, amantadine and ketamine, reduce vasospasm

Question 6

Clinical symptoms of rabies infection

Answer 6

1) Non-specifc prodrome (d0-10) - fever, fatigue, headaches, respiratory and gastro symptoms, irritability, paraesthesia

2) Neurological phase (2-7 days) - hydrophobia, aerophobia, personality changes, inspiratory spasms, hypersalivation, hallucinations. Can be a) furious (encephalitic) or b) paralytic.

3) Death (1-7 days) Respiratory arrest, coma and death

Question 7

a) Ante-mortem diagnosis of rabies

b) Post-mortem diagnosis of rabies

Answer 7

a) RT-PCR - saliva and punch biopsy of the nape of neck

Antigen detection in hair follicles

Neutralising Ab detection in serum and CSF (only in unvaccinated)

b) Brain biopsy - RT-PCR, fluorescent Ab test, histology for negri bodies