Rabies

Furious/encephalitic	Dumb/Paralytic
Hydrophobia/aerophobia Hyperactivity Disorientation Combative behaviour Alternating periods of lucidity Spasms Pharyngeal pain/difficulty swallowing Hypersalivation	General Malaise Headache Ascending paralysis leading to quadriplegia with sphincter involvement

Important points in history

All age groups
History of animal contact, e.g. Bite, Scratch, Claws
Animal's behaviour (?sick, ?tests by veterinarian)
Over wounds site:
- Pain
- Pruritis
- Paraesthesia
Fever
Malaise
Headache
Vomiting
Anorexia
Symptoms of autonomic instability e.g. unstable temperature, sweaty, piloerection, priapism

Important points on examination

ABC
BCS
Seizures/ agitation
Aerophobia
Hydration status
Neuro-flaccidity, hyporeflexia
+/- hypotension

Investigations

Water test if necessary but this can be very distressing.
Fan test (patients have severe aerophobia)
At post mortem, a supra orbital brain biopsy can be performed

Differential Diagnosis

Meningitis
Tetanus
Cerebral Malaria
GBS for paralytic rabies
Other viral encephalitis

Management

Establish what category of exposure. Per the WHO guidelines an exposure is any of the following, from any mammal – but especially from dogs:

Post exposure prophylaxis (immediately after a (possibly) rabid dog bite)

Local wound care - must be washed for 15 minutes with water and iodine (or soap if iodine is not available) and then cleaned with antiseptic (in case of a mucus membrane exposure flush the area with copious amounts of clean water). Do not suture if there is an open wound.

The patient should get a certificate from the Government Veterinary Laboratory. This will allow them to get free rabies post-exposure vaccines from the DHO pharmacy and Gateway clinic.
If the animal is suspected of being rabid call the Mission Rabies Hotline on 088531992 / 0992566022

Antibiotics

(e.g. Augmentin: 22.5 mg/kg per dose (amoxicillin component) BD (maximum 875 mg amoxicillin and 125 mg clavulanate per dose)
plus
Metronidazole: 10 mg/kg per dose TDS (maximum 500 mg per dose))

Vaccines

TTV see Immunisation protocol

Give the Anti-rabies (chick embryo) vaccine at days 0, 3, 7, 14, 30 and 90
It is given IM into the deltoid muscle,
The first dose is given at the nearest health unit & subsequent doses by the DHO
Interaction of vaccine: with IM antimalarials, immunosuppressive drugs & steroids
Complications of the vaccine: include local reactions e.g. urticarial rash and general
The vaccine has occasionally caused a post rabies vaccine encephalomyelitis (although this is very rare with chick or duck embryo derived vaccine)
The vaccine in QECH is available on request from the pharmacy

Consider also

Have any other children been bitten? If so, they will also require vaccination
Consider vaccines for those exposed due to occupational and recreational reasons
Has the offending dog/animal been seen by a vetinary surgeon. If it is a stray dog assume dog is rabid until proved otherwise.

Management of clinical cases of Rabies ENCEPHALITIS

Treatment is supportive.

Sedation
- Diazepam and/or Phenobarbitone -> Infuse in an IV drip. Ask a senior for advice
- +/- Analgesics
- Consider chloralhydrate. Via NGT
IV fluids - insert IV as soon as safely possible. Patients frequently complain of dehydration in lucid periods.
Broad spectrum antibiotics cover if patient febrile/ critically unwell/ doubt over diagnosis
Manage in a side-room/ quiet area.
Counsel the family - involve Palliative care