Rabies Meningoencephalomyelitis presenting as Guillain Barré Syndrome

Abstract

A 20-year-old male, hailing from Haryana, presented to medicine emergency in the month of October, with 5 days history of acute onset paralysis of all four limbs, worsening to involve the respiratory and truncal muscles. Illness was preceded by fever lasting for 3 days. He had history of dog bite with inadequate postexposure vaccination, 3 months prior to the current illness. On examination, there was hypotonia, arreflexic quadriparesis along with respiratory, bifacial, palatal, neck and truncal muscle weakness. He developed photophobia, neck stiffness, worsening sensorium and respiratory efforts, for which he was managed with mechanical ventilation in intensive care unit (ICU) setting. Investigations revealed mild leukocytosis (TLC: 12,800) and normal electrolytes, renal function test, chest X-ray and ECG. CSF revealed neutrophilic pleocytosis (100 cells P70 L30) and elevated protein with normal sugars (Pr/S: 120/60; corresponding blood sugar (CBS): 97 mg/dl). Human immunodeficiency virus (HIV) serology was negative, X-ray chest was within normal limits. Nerve conduction study was suggestive of sensorimotor axonal polyradiculopathy [Rt median CMAP reduced, Rt ulnar, peroneal, tibial were nonstimulable, Rt median and ulnar sensory nerve action potential (SNAP) was reduced]. Corneal smear was negative for rabies antigen and contrastenhanced magnetic resonance imaging (CE-MRI) brain was planned. A clinical possibility of Landry Guillain-Barre syndrome (LGBS) and rabies was kept. The patient could not afford intravenous immunoglobulins (IVIG) or plasmapheresis, and so he was started on injection methylprednisolone, 1 gm bolus once a day and empirically covered for bacterial meningitis with antibiotics. Other supportive measures continued. During the stay, he also had fluctuations in blood pressures with minimum of 110/70 to maximum of 150/90 mm Hg. On day third patient’s sensorium further worsened and cardiac monitor showed bradycardia, following which he sustained a cardiac arrest and could not be revived.