Epidemiologic Notes and Reports Human Rabies Acquired
Outside the United States
The third case of human rabies reported to CDC in 1984 was
diagnosed in California in October 1984 in a 72-year-old Guatemalan
citizen. The patient reported that, in an unprovoked attack in
Guatemala in early June, she was bitten on her right ankle by a
stray
dog that could not be found for examination. On September 3, she
first noted weakness of her right leg. She left Guatemala that day
to
visit her daughter in California. When she deplaned in California
that evening, she was unable to walk without assistance. By
September
6, she was unable to stand and was hospitalized.
At the time of admission, the patient was alert, communicative,
and afebrile. She reported receiving shots at the time of her bite
and was thought to have received rabies postexposure prophylaxis.
The
only abnormality detected on physical examination was right lower
extremity weakness. Agitation and confusion developed on the night
of
admission. Computerized tomographic examination of her head was
unremarkable. On September 9, a lumbar puncture revealed a
cerebrospinal fluid white blood cell count of 6 lymphocytes per
mm((3)), an elevated protein (65 mg/dl), and a normal glucose.
Later
that day, she developed aspiration pneumonia and required
mechanical
ventilation. Paralysis progressed to involve all extremities, and
her
mental status declined. Despite supportive care, she became
comatose
and died October 1.
At autopsy, because of the clinical course of progressive
encephalitis, brain tissue was examined and found positive for
rabies
by direct fluorescent antibody testing. Questioning of family
members
revealed that, following the dog bite, the patient had received
only
local wound care and a single intramuscular injection (presumably
tetanus toxoid). The delay in diagnosis necessitated administering
postexposure prophylaxis to 179 persons exposed to the patient,
including 12 family members.
Adapted from California Morbidity (November 9, 1984); reported by
Div
of Viral Diseases, Center for Infectious Diseases, CDC.
Editorial Note
Editorial Note:Ten (43%) of the 23 human rabies cases reported to
CDC
from 1975 through 1984 were acquired outside the United States;
these
include six acquired by U.S. citizens living outside the United
States
and four acquired by non-U.S. citizens outside the United States
and
diagnosed in the United States. There were histories of probable
exposure to rabies from a dog bite in eight of the 10 cases. In
the
eight cases, the development of rabies was attributable to: failure
to
seek treatment (three cases), postexposure therapy not recommended
(two), delay in seeking treatment (one), failure to receive rabies
immune globulin as part of postexposure therapy (one), and
misdiagnosis of the exposing animal (one).
All persons traveling to rabies-endemic areas outside the
United
States should be made aware of the risk of exposure to rabies and
the
importance of local wound treatment, medical advice, and rabies
biologics. Persons traveling to developing countries where rabies
control programs for domestic animals are not optimal should be
offered preexposure prophylaxis if they plan to stay for more than
30
days (1). Every 2 years, persons on long-term international
assignments in rabies-endemic areas who are at risk of an
inapparent
exposure to rabies or a delay in postexposure prophylaxis should be
advised to have a booster or have their serum tested for
rabies-neutralizing antibody and, if their titer is inadequate,
have a
booster. It should be emphasized that preexposure prophylaxis does
not eliminate the need for prompt postexposure prophylaxis if an
exposure to rabies occurs.
Rabies should be considered in any case of encephalitis or
myelitis of unknown etiology, even in the absence of an exposure
history, particularly in a person who has lived or traveled outside
the United States.
In the United States, state health departments should be
consulted
for assistance in reviewing the techniques for diagnosing rabies in
suspected rabid animals and the therapeutic measures received by
any
person exposed to rabies outside the United States. If assistance
is
needed outside the United States, a United States Embassy or
consulate
can be contacted.
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