Atypical paralytic rabies — A case-study from Kerala, India

Abstract

Rabies, though endemic in India, has been a disease of low public health priority throughout the years. Being a non-notifiable disease together with limited diagnostic facilities, it often ends up in under-reporting of cases, especially atypical rabies. Failure of complete rabies Post Exposure Prophylaxis (PEP) with Immunoglobulin has been rarely reported. We report a case of atypical rabies in a 60-year-old man from a rural village in Kerala, who presented with fever, paralysis of limbs, fluctuating consciousness, phonophobia and without classical signs of hydrophobia and aerophobia 22 days after dog bite. The case is supplemented with supportive Magnetic Resonance Imaging (MRI) findings and corneal imprint smear Fluorescent Antibody Test (FAT). The death of the patient on the 28th day of exposure despite early PEP with rabies vaccine and immunoglobulin is suggestive of PEP failure. The case study stresses on the need in making rabies a notifiable disease in the study setting, encouraging disease specific investigation, ensuring availability of vaccine and immunoglobulins with adherence to standardized treatment protocols.Deviations from the recommended protocol for Animal bite management, such as delay in seeking PEP, lack of or improper administration of rabies immunoglobulin (e.g. missing out bite sites), lack of or improper primary wound care, and/or poor-quality rabies vaccine, may lead to death.