Today’s Morning Report is presented by Dr. Christopher!
Rabies
Background
- One of the deadliest viruses known – case fatality rate 100%
- Zoonotic – carried by warm blooded animals
- Fatal if post-exposure prophylaxis is not initiated prior to symptoms
- Majority of deaths occur in Asia/Africa
Pathophyisiology
- Lyssavirus – RNA virus
- Binds to muscle or nerve cells
- Virus travels along nerves to the CNS and other sites to generate symptoms
- Incubation – 2 to 12 weeks – varies depending on site of entry
- Early symptoms – non-specific – headache, malaise, fever,
- Late symptoms – seizures, myoclonus, agitation, depression, lethargy, heart failure
- Hydrophobia – saliva production is greatly increased + spasms in the muscles of the throat/larynx
- Diagnosis – clinical – PCR from skin or brain tissue
Prevention
- Vaccine developed in 1885 by Louis Pasteur – harvested from infected rabbits
- Widespread vaccination in the US has reduced deaths from 100/year to 1-2/year
Treatment
- PEP should begin as soon as possible after the presumed exposure.
- What to administer — Rabies immunoglobulin is referred to as “passive immunization”; rabies vaccine is referred to as “active immunization”.
- Vaccine alone is given for preexposure prophylaxis
- Post-exposure rabies prophylaxis, in previously unimmunized persons, should always include both passive and active immunization.
- POST Exposure prophylaxis
- Vaccine administration (4 doses) – day 0, 3, 7, 14, (28) – fifth does given if immunocompromised
- If previously vaccinated – re-vaccinate on day 0 and day 3
- Must have documented antibody titer – takes 7 days to mount antibody response
- Never administer in gluteal region (low titers noted)
- Rabies Immune Globulin (RIG)
- Pooled plasma from hyperimmunized human donors or horses (HRIG recommended, no noted transmission of infection)
- ½ life of 3 weeks
- Dose – HRIG 20u/kg; Equine RIG 40u/kg
- Should be infiltrated around the area of the wound and in an additional site other than the vaccine site
- Wound Care – most important initial step – reduces transmission by 90%
- Use a virucidal – betadyne
- Other – Tetanus PPX, ABxm,mn
- Vaccine administration (4 doses) – day 0, 3, 7, 14, (28) – fifth does given if immunocompromised
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Jay Khadpe MD
- Editor in Chief of "The Original Kings of County"
- Assistant Professor of Emergency Medicine
- Assistant Residency Director
- SUNY Downstate / Kings County Hospital
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