Guidelines for the diagnosis and treatment of patients with encephalitis were prepared by an Expert Panel of the Infectious Diseases Society of America. The guidelines are intended for use by health care providers who care for patients with encephalitis. The guideline includes data on the epidemiology, clinical features, diagnosis, and treatment of many viral, bacterial, fungal, protozoal, and helminthic etiologies of encephalitis and provides information on when specific etiologic agents should be considered in individual patients with encephalitis.

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The Management of Encephalitis: Clinical Practice Guidelines by the Infectious Diseases Society of America

We report the survival of a 15-year-old girl in whom clinical rabies developed one month after she was bitten by a bat. Treatment included induction of coma while a native immune response matured; rabies vaccine was not administered. The patient was treated with ketamine, midazolam, ribavirin, and amantadine. Probable drug-related toxic effects included hemolysis, pancreatitis, acidosis, and hepatotoxicity. Lumbar puncture after eight days showed an increased level of rabies antibody, and sedation was tapered. Paresis and sensory denervation then resolved. The patient was removed from isolation after 31 days and discharged to her home after 76 days. At nearly five months after her initial hospitalization, she was alert and communicative, but with choreoathetosis, dysarthria, and an unsteady gait.

https://www.nejm.org/doi/pdf/10.1056/NEJMoa050382

Survival after Treatment of Rabies with Induction of Coma

Background In 2004, four recipients of kidneys, a liver, and an arterial segment from a common organ donor died of encephalitis of an unknown cause. Methods We reviewed the medical records of the organ donor and the recipients. Blood, cerebrospinal fluid, and tissues from the recipients were tested with a variety of assays and pathological stains for numerous causes of encephalitis. Samples from the recipients were also inoculated into mice. Results The organ donor had been healthy before having a subarachnoid hemorrhage that led to his death. Encephalitis developed in all four recipients within 30 days after transplantation and was accompanied by rapid neurologic deterioration characterized by agitated delirium, seizures, respiratory failure, and coma. They died an average of 13 days after the onset of neurologic symptoms. Mice inoculated with samples from the affected patients became ill seven to eight days later, and electron microscopy of central nervous system (CNS) tissue demonstrated rhabdovirus pa...

Transmission of rabies virus from an organ donor to four transplant recipients.

These recommendations of the Advisory Committee on Immunization Practices (ACIP) update the previous recommendations on human rabies prevention (CDC. Human rabies prevention--United States, 1999: recommendations of the Advisory Committee on Immunization Practices. MMWR 1999;48 [No. RR-1]) and reflect the status of rabies and antirabies biologics in the United States. This statement 1) provides updated information on human and animal rabies epidemiology; 2) summarizes the evidence regarding the effectiveness/efficacy, immunogenicity, and safety of rabies biologics; 3) presents new information on the cost-effectiveness of rabies postexposure prophylaxis; 4) presents recommendations for rabies postexposure and pre-exposure prophylaxis; and 5) presents information regarding treatment considerations for human rabies patients. These recommendations involve no substantial changes to the recommended approach for rabies postexposure or pre-exposure prophylaxis. ACIP recommends that prophylaxis for the prevention of rabies in humans exposed to rabies virus should include prompt and thorough wound cleansing followed by passive rabies immunization with human rabies immune globulin (HRIG) and vaccination with a cell culture rabies vaccine. For persons who have never been vaccinated against rabies, postexposure antirabies vaccination should always include administration of both passive antibody (HRIG) and vaccine (human diploid cell vaccine [HDCV] or purified chick embryo cell vaccine [PCECV]). Persons who have ever previously received complete vaccination regimens (pre-exposure or postexposure) with a cell culture vaccine or persons who have been vaccinated with other types of vaccines and have previously had a documented rabies virus neutralizing antibody titer should receive only 2 doses of vaccine: one on day 0 (as soon as the exposure is recognized and administration of vaccine can be arranged) and the second on day 3. HRIG is administered only once (i.e., at the beginning of antirabies prophylaxis) to previously unvaccinated persons to provide immediate, passive, rabies virus neutralizing antibody coverage until the patient responds to HDCV or PCECV by actively producing antibodies. A regimen of 5 1-mL doses of HDCV or PCECV should be administered intramuscularly to previously unvaccinated persons. The first dose of the 5-dose course should be administered as soon as possible after exposure (day 0). Additional doses should then be administered on days 3, 7, 14, and 28 after the first vaccination. Rabies pre-exposure vaccination should include three 1.0-mL injections of HDCV or PCECV administered intramuscularly (one injection per day on days 0, 7, and 21 or 28). Modifications were made to the language of the guidelines to clarify the recommendations and better specify the situations in which rabies post- and pre-exposure prophylaxis should be administered. No new rabies biologics are presented, and no changes were made to the vaccination schedules. However, rabies vaccine adsorbed (RVA, Bioport Corporation) is no longer available for rabies postexposure or pre-exposure prophylaxis, and intradermal pre-exposure prophylaxis is no longer recommended because it is not available in the United States.

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Human rabies prevention--United States, 2008 : recommendations of the Advisory Committee on Immunization Practices

Summary—During 2004, 49 states and Puerto Rico reported 6,836 cases of rabies in nonhuman animals and 8 cases in human beings to the CDC, representing a 4.6% decrease from the 7,170 cases in nonhuman animals and 3 cases in human beings reported in 2003. Approximately 92% of the cases were in wildlife, and 8% were in domestic animals (compared with 91% and 9%, respectively, in 2003). Relative contributions by the major animal groups were as follows: 2,564 raccoons (37.5%), 1,856 skunks (27.1%), 1,361 bats (19.9%), 389 foxes (5.7%), 281 cats (4.1%), 115 cattle (1.7%), and 94 dogs (1.4%). Compared with the numbers of reported cases in 2003, cases in 2004 decreased among all groups, except bats, cattle, human beings, and “other domestics” (1 llama). Decreases in numbers of rabid raccoons during 2004 were reported by 12 of the 20 eastern states in which raccoon rabies was enzootic. In the East, Massachusetts reported the first cases of raccoon rabies detected beyond the Cape Cod oral rabies vaccine barrier. Along the western edge of the raccoon rabies epizootic (Ohio in the north and Tennessee in the south), cases of rabies were reported from unexpected new foci beyond oral rabies vaccine zones. On a national level, the number of rabies cases in skunks during 2004 decreased by 12.1% from the number reported in 2003. Once again, Texas reported the greatest number (n = 534) of rabid skunks and the greatest overall state total of rabies cases (913). Texas reported only 1 case of rabies in a dog that was infected with the dog/coyote rabies virus variant and only 22 cases associated with the Texas gray fox rabies virus variant (compared with 61 cases in 2003). The total number of cases of rabies reported nationally in foxes and raccoons declined 14.7% and 2.7%, respectively, during 2004. The 1,361 cases of rabies reported in bats during 2004 represented a 12.3% increase over the previous year’s total of 1,212 cases for this group of mammals. Cases of rabies reported in cats, dogs, horses and mules, and sheep and goats decreased 12.5%, 19.7%, 31.8%, and 16.7%, respectively, whereas cases reported in cattle increased 17.4%. In Puerto Rico, reported cases of rabies in mongooses decreased 4.1% and rabies in dogs (9 cases) remained unchanged from those reported in 2003. Among the 8 cases of rabies in human beings, 1 person from Oklahoma and 3 from Texas died following receipt of infected organs and tissues from an Arkansas donor. In California, a person originally from El Salvador and, in Florida, a person originally from Haiti both died of canine rabies infections acquired outside the United States. In Wisconsin, a teenager contracted rabies from a bat bite and became the first known person to survive rabies despite not having received rabies vaccine prior to symptom onset.

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Hl Dhonau

Papers

Recovery of a patient from clinical rabies - Wisconsin, 2004