Rabies, human - USA: MMWR reports

Date: 15 Dec 2000 16:23:55 GMT+0200
From: MMWR 15 Dec 2000 / 49(49);1111-5


Human Rabies: California, Georgia, Minnesota, New York, and Wisconsin, 2000
-----------------------------------
On 20 Sep; 9, 10, 25 Oct; and 1 Nov 2000, persons who resided in
California, New York, Georgia, Minnesota, and Wisconsin, respectively, died
of rabies. This report summarizes the case investigations.

California:
On 15 Sep, a 49-year-old man visited a neurologist with 2 days of
increasing right arm pain and paresthesias. The neurologist diagnosed
atypical neuropathy. The symptoms increased and were accompanied by hand
spasms and sweating on the right side of the face and trunk. The patient
was discharged twice from an emergency department but symptoms
worsened. After developing dysphagia, hypersalivation, agitation, and
generalized muscle twitching, the patient was admitted to a local hospital
on 16 Sep. Vital signs and blood tests were normal, but within hours he
became confused. The consulting neurologist suspected rabies. Rabies
immune globulin, vaccine, and acyclovir were administered. On 17 Sep the
patient was placed on mechanical ventilation and rabies tests returned
positive. Renal failure developed and the patient died on 20 Sep. The
patient did not report contact with a bat, although his wife reported that
in June or July a bat had flown into their house and the patient had
removed it.

New York:
On 22 Sep a 54-year-old man who had resided in Ghana arrived in the United
States, and on 26 Sep reported discomfort in his right lower back. During
the next few days, the pain intensified and alternated with abdominal
discomfort. He developed restlessness and anxiety. On 30 Sep he was
admitted to a local hospital for suspected bowel obstruction. On
examination, the patient appeared anxious and had right flank tenderness,
diaphoresis, spontaneous ejaculation, soft tissue swelling of the right
lumbar area, vomiting, and a temperature of 99.3 F (37.4 C). Other
symptoms appeared within hours, including dysphagia, dizziness, shortness
of breath, and paranoia. The patient became delirious, with frothing and
agitation. On 1 Oct the patient had a cardiac arrest, was resuscitated and
placed on mechanical ventilation. Rabies tests were positive on 3
Oct. After a gradual decrease in respiration, heart rate, and blood
pressure, the patient died on 9 Oct. History from the patient's employer
in Ghana revealed that the patient had been bitten in Ghana on his thumb
and leg by his unvaccinated puppy in May 2000.

Georgia:
On 3 Oct a 26-year-old man developed intractable vomiting and
hematemesis. At a local hospital, he was treated with antiemetic
suppositories; that evening he became disoriented, combative, and had
difficulty breathing. On 5 Oct he became hypotensive and hypoxic and was
transferred to a referral hospital for ventilatory support. Examination
revealed a temperature of 104 F (40 C), anisocoria, copious oral
secretions, scattered bilateral pulmonary crackles, and a white blood cell
count (WBC) of 46.6 cells x 109/L (normal: 5--10 x 109/L). A chest
radiograph revealed bilateral diffuse alveolar densities. Broad spectrum
antibiotics, including acyclovir, were initiated. On 9 Oct the patient
developed cardiac arrhythmia, hypotension, and became combative,
necessitating sedative and paralytic agent therapies. He developed
respiratory and renal failure and died on 10 Oct. Since July, the patient
had been renting a room on the upper floor of an old house. He had
reported to co-workers that bats from the attic had entered his living
quarters and landed on him while he slept. Investigation of the house
occupied by the patient since July 2000 revealed a colony of approximately
200 Mexican free-tailed bats in the attic and openings between the attic
and the patient's bedroom, bathroom, closet, and kitchen.

Minnesota:
On 14 Oct a 47-year-old man visited a local clinic with 6 days of worsening
right arm pain and parasthesias. He developed decreased right finger
movement 2 days later. Nerve conduction studies were consistent with
carpal tunnel syndrome. On 19 Oct while travelling in North Dakota, the
patient was admitted to a North Dakota hospital with a temperature of 103 F
(39.4 C), flaccid paralysis and sensory loss in the right upper extremity,
sensory loss in the mid-thoracic area, hypoesthesia and hyporeflexia in the
left upper extremity, and anisocoria. Laboratory findings were normal
except a WBC count of 13.8 x 109/L. The patient was placed on broad
spectrum antibiotics. On 20 Oct the patient developed acute respiratory
failure and was intubated. Magnetic resonance imaging was consistent with
myelitis and ganciclovir was added to antibiotic coverage. He died on 25
Oct. It was learned that 3 days earlier, a friend told the family that
during 11-19 Aug, the patient had been awakened by a bat on his right
hand. He killed the bat and was bitten in the process. The patient did
not seek medical care. Investigation found in the patient's house multiple
portals of entry for bats, openings between the attic and living areas, and
extensive deposits of guano in the attic and living area.

Wisconsin:
On 14 Oct a 69-year-old man with a 2-day history of chest discomfort and
numbness, tingling, and tremors of the left arm was admitted to a local
hospital for cardiac evaluation. On 16 Oct, the patient had onset of
progressive dysphagia, diaphoresis, delirium, and myoclonus. The patient
was treated with intravenous antibiotics for possible sepsis and acyclovir
for suspected herpes encephalitis. He developed renal insufficiency
requiring hemodialysis and respiratory failure necessitating mechanical
ventilation. A serum rapid fluorescent focus inhibition test for rabies
antibodies was negative on 18 Oct. The patient died on 1 Nov, and
postmortem examination of the brain revealed Negri bodies. Subsequent
testing confirmed a diagnosis of rabies. The patient had told a friend
that 2-3 times a year he had removed bats from his house with his bare
hands; several other residences used by the patient also had potential
portals for the entry of bats. He did not mention being bitten by an
animal but had asked a friend a week before admission if rabies could be
acquired from an insect bite.

Reported by: D Van Fossan, MD, Sutter Amador Hospital; L Jagoda, PHN, A
LeSage, PHN, R Hartmann, MD, Amador County Health Dept; Amador County
Rabies Task Force, Jackson; J Johl, MD, J Sharman, Univ of California Davis
Medical Center, Sacramento; M Jay, DVM, D Schnurr, PhD, L Crawford-Miksza,
PhD, C Glaser, MD, D Vugia, MD, Acting State Epidemiologist, California
Dept of Health Svcs. R Leach, MD, K Cantiello, MS, Glens Falls Hospital; P
Auer, MA, G Jones, Warren County Health Dept, Glens Falls; J Qian, MD, P
Depowski, MD, Albany Medical Center, Albany; P Downing, Washington County
Health Dept, Hudson Falls; C Trimarchi, MS, C Huang, PhD, P Drabkin, MPH, M
Eidson, DVM, B Wallace, MD, A Willsey, DVM, P Smith, MD, State
Epidemiologist, New York State Dept of Health. L Ahadzie, MD, Ghana
Ministry of Health, Accra, Ghana. HP Katner, MD, Mercer Univ School of
Medicine, Macon; M Rahman, MD, OI Muraina, MD, JP Tift, MD, Medical Center
of Central Georgia, Macon; D Shetty, MD, Peach County Medical Center, Fort
Valley; CL Drenzek, DVM, S Lance-Parker, DVM, D Cantrell, PhD, E Saidla, Z
Koppanyi, MD, West Central Health District, Columbus; PA Blake, MD, State
Epidemiologist, Georgia Div of Public Health. T Boldingh, DVM, Minnesota
Board of Animal Health, St. Paul; L Wagstrom, DVM, R Danila, PhD, J
Mariotti, KE Smith, DVM, D Neitzel, MS, HF Hull, MD, Minnesota Dept of
Health. Dakota Heartland Hospital, Fargo; L Shireley, MPH, D Johnson, MS, R
Patron, MD, North Dakota Dept of Health. WE Scheckler, MD, JM Levin, MD, M
Dominski, MD, St. Mary's Hospital Medical Center, Madison; M Wolff, B
Muhlenbeck, MPH, Sauk County Health Dept, Baraboo; RC Turner, MD, Reedsburg
Area Medical Center, Reedsburg; J Kazmierczak, DVM, M Proctor, PhD, JP
Davis, MD, Wisconsin Div of Public Health. Viral and Rickettsial Zoonoses
Br, Div of Viral and Rickettsial Diseases, National Center for Infectious
Diseases; and EIS officers, CDC.

MMWR Editorial Note:
These 5 cases of human rabies are the first diagnosed in the United States
since December 1998, and underscore that rabies should be considered in any
patient with progressive encephalitis. The initial presentations of rabies
can be diverse and a history of animal contact is rarely obtained. Because
the immune response to rabies may not occur until late in the disease, if
rabies is suspected, an antemortem examination should include a nuchal skin
biopsy, saliva, and cerebral spinal fluid or a postmortem examination of
central nervous system tissue (1).

In the United States since 1990, infection with indigenous rabies virus
variants associated with insectivorous bats and infection with foreign
canine rabies virus variants have accounted for 30 of the 32 human
cases. Although 24 (74%) of the 32 cases since 1990 have been attributed
to bat-associated variants of the virus, a history of a bite was
established in only 2 cases. Contact with bats occurred in approximately
half of the other cases. These cases represent various bat-contact
histories: a bat bite, direct contact with bats with multiple opportunities
to be bitten, and possible direct contact with a bat. Canine rabies is
prevalent in Africa, Asia, and Latin America. Worldwide estimates of human
rabies deaths exceed 50 000 cases each year, and >95% of reported cases
occur in regions where canine rabies is endemic (2).

Although rabies is usually transmitted by a bite, persons may minimize the
medical implications of a bat bite. Unlike bites from larger animals, the
trauma of a bat bite is unlikely to warrant seeking medical care. Unless
the potential for rabies exposure is known to the patient, rabies
postexposure prophylaxis (PEP) will not be received. Although bat rabies
virus variants can be transmitted secondarily from terrestrial mammals, the
lack of other animal-bite histories and the rarity of bat rabies virus
variants found in terrestrial mammals suggest that this means of
transmission is rare (3).

Persons who are bitten or scratched by any animal should wash wounds
thoroughly and seek immediate medical attention to evaluate the need for
PEP. In all cases where bat-human contact has occurred or is suspected,
the bat should be collected and tested for rabies. If the bat is
unavailable, the need for PEP should be assessed by public health
officials. PEP should be considered after direct contact between a human
and a bat, unless the exposed person can be certain a bite, scratch, or
mucous membrane exposure did not occur. PEP may be considered for persons
who were in the same room as a bat and who might be unaware that a bite or
direct contact had occurred (e.g., when a sleeping person wakes to find a
bat in the room or an adult witnesses a bat in the room with an unattended
child, mentally disabled person, or intoxicated person). PEP is not
warranted when direct contact between a human and a bat did not
occur. Seeing a bat or being in the vicinity of bats does not constitute
an exposure (4).

References
1. CDC. Essential characteristics for routine rabies tests. Available at
. Accessed Dec 2000.
2. Haupt W. Rabies---risk of exposure and current trends in prevention of
human cases. Vaccine 1999;17:1742--9.
3. Baer GM, Smith JS. Rabies in non-hematophagous bats. In: Baer GM, ed.
The natural history of rabies. 2nd ed. Boca Raton, Florida: CRC Press,
1991:341--66.
4. CDC. Human rabies prevention---United States, 1999: recommendations of
the Advisory Committee on Immunization Practices (ACIP). MMWR 1999;48 (no.
RR-1).

--
ProMED-mail


[As mentioned in the MMWR editorial comments above, these are the first
cases of human rabies since December of 1998. In fact, December's case was
the only one in 1998. However, 1997, 1996 and 1995 each had 4 cases; 1994
had 5 cases; 1993 3 cases, 1992 1 case and 1991 3 cases. In the1980s there
were even fewer human cases than the last decade. Just like the early
debates on global warming, we can ask: are these an unusually high number
of cases indicative of a trend or just normal year-to-year
variability? Only time will tell; but an upward tick in the data series
isn't unprecedented. Additionally, the case histories provide interesting
reading concerning exposures, a lapse of recognition by patients of the
danger involved, and the wide varia

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