Morning Report: 11/14/2013

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

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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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