Rabies vaccine
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Vaccine failure: case report An 11-year-old boy exhibited rabies vaccine failure following administration for post-exposure prophylaxis in India. The boy presented to the paediatric emergency room of hospital in India due to abnormal tingling sensation and weakness of his right arm for 5 days. One month prior, he had class 3 dog bite over the right wrist. Thereafter, he had received five doses of intradermal purified chick embryo cell rabies vaccine as post-exposure prophylaxis and unspecified local wound care. He did not receive rabies immunoglobulin and was feeling well for one month. However, he developed right-hand paraesthesia, flaccid weakness, encephalopathy and progressive quadriparesis. On examination, he had sluggishly reacting pupils and autonomic dysfunction with hypertension and bradycardia. A spinal MRI revealed presence of brachial plexitis and longitudinal extensive myelitis including cervical spine. A brain MRI revealed hyperintensities in the bilateral basal ganglia, pons and hippocampal region. Lumbar CSF examination showed presence of lymphocytes, protein and glucose. A CSF culture was sterile and real time PCR was negative for viral RNA. Paired serum samples revealed increased levels of rabies neutralising antibodies over 3 weeks, and CSF showed an antibody titer of 1:2048. These findings suggested rabies encephalitis requiring intubation and mechanical ventilation. The boy was treated with unspecified antihypertensives and antibiotics for health care associated infection. During third week of his hospitalisation, he required tracheostomy for upper airway protection. He was treated with methylprednisolone, meropenem, ceftriaxone and immune-globulin using barrier nursing technique for 5 days and high dose dexamethasone for one week gradual tapering. A CSF analysis for autoantibodies including AMPA1, NMDA, AMPA2, LG1, CASPER, GABA receptor B1 and B2 were negative. He was treated with simvastatin and high dose vitamins with expert advice. He remained hospitalised for 6 weeks and was discharged in a minimally conscious state with rigidity, dystonia and quadriparesis. His discharge medications included simvastatin, clonidine and high dose multivitamins with tracheostomy and nasogastric tube in situ. At 4 months follow-up visit, a repeat MRI revealed significant cystic necrotic alteration in bilateral basal ganglia, and atrophy of the cerebral cortex, hippocampus and thalamus. During his recent follow-up visit at 12 months, a minimal improvement in his neurological status was observed with response to touch, pain and sound with persistent dystonic and rigidity quadriplegic state. Goyal K, et al. Enigma of Rabies: Prolonged Survival in a Boy with Rabies Brachial Plexitis and Encephalomyelitis. Neurology India 68: 673-676, No. 3, Jun 2020. Available 803501370 from: URL: http://doi.org/10.4103/0028-3886.288993
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Reactions 19 Sep 2020 No. 1822
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