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Emergency Strategy - How to treat rabies

Emergency Strategy - How to treat rabies
Patient is admitted if developing symptoms and signs of rabies and encephalitis. The initial steps include assessment of the patient ‘s airway, breathing, circulation , disability and exposure. The affected area is wash thoroughly with soap, virucidal agent and water. The animal which bites the patient should be captured if possible for diagnosing the rabies. Tetanus immunization is considered.The affected domestic animal should be monitored for 10 days. Patient may not required secondary prophylaxis if animal caputred does not present with any symptoms and signs.
In case of wild animal, rabies should be tested if we able to catch the animal.Patient should be treated post exposure prophylaxis if the animal is failed to be captured. Post exposure prophylaxis is a proven treatment which is given to high risk individual.
Post exposure prophylaxis include passive immunization with human rabies immunoglobulin.20 IU/kg of human rabies immunoglobulin is required. Half of the dose is given intramuscularly while the other half of the dose is infiltrated around or at the wound.
Next consider immunization with active immunization of rabies vaccine. Avoiding vaccine administration to the gluteus due to administration to the subcutaneous fat. The active vaccine is administered into the thigh in children and deltoids in adult. There are few vaccines which include rabies vaccine adsorbed, human diploid vaccine intramuscularly and purified chick embryo cell vaccine. These vaccine also known as RabAvert, Imovax. If the patient had pre exposure prophylaxis and suffered from rabies infection consider vaccine booster on days 0 and 3. Passive immunization with human rabies immunoglobulin is avoided in this case.
In cases where the action to treat is delayed after exposure to rabies, consider administration of the vaccine as usual. Passive immunization with human immunoglobulin is not given.
Target groups such as foreign travelers in endemic areas, virus laboratory workers, animal handlers and veterinars may required pre exposure prophylaxis ( rabies vaccine on day 0, 7, 21, 28). Patient will be discharge if there is no evidence of rabies and the patient is stable. Patient should be followed and ensure the patient has adequate exposure to subsequent vaccine administered post exposure to rabies.
Patient may present with three manifestation of rabies which include paralytic dumb rabies ( 40%) which present as ascending paralysis that mimic Guillain Barre syndrome, encephalitis ( 80%) with persistent of neurological deficit and 1% of patient may suffer from sensory and motor deficit, seizure, myoclonus, choreiform movement and neuropathic pain.Rabies are presented with 5 stages. The stages are latent period, prodrome, encephalitis and coma which finally lead to death.
In latent period, the virus is incubated at the peripheral tissue. The latent period is around 1- 3 months. However it may last for a shorter period if it involves the bite to the neck or head.
The prodrome period is presented with nausea, vomiting, myalgia, fever, anorexia, malaise, headache and sore throat. Around the sited of the bite, the patient may also complain of fasciculation and paraesthesia. The prodrome period will last for 1- 7 days.
Patient may suffer from encephalitis, which include seizures, confusions, high fever, agitation, anxiety, deliriums and hallucinations. Besides that, patient may present with facial paralysis, diplopia, hydrophobia ( patient who try to swallow may suffer from violent involuntary contraction of the accessory muscle of the respiration, laryngeal, pharyngeal and diaphragmatic muscle. Patient may also suffer from pharyngeal spasm form air ( aerophobia). Myocarditis, autonomic instability ( dilated pupil, orthostatic hypotension, perspiration and hypersalivation) as well as dysrhythmias may also occur,
Besides that patient may suffer from flaccid paralysis, adult respiratory distress syndrome and inappropriate secretion of antidiuretic hormone. Patient will fall into coma and die if no pre or post exposure prophylaxis are given within 2 weeks.
The investigations require are full blood count, urea and electrolytes, creatinine, blood glucose, blood culture, urinalysis, saliva studies ( isolation of virus in cell culture, detection of rabies RNA by reverse transcriptase polymerase chain reaction) and serum ( detection of rabies on antibodies) as well as lumbar puncture ( to evaluate CSF which usually high in white blood cell, high in protein and normal level of glucose). Biopsy of the neck is considered. Further test such as immunofluorescent staining and reverse transcriptase polymerase chain reaction may also be considered. Chest x ray is useful to rule out possibilities of chest infection. CT scan is useful to rule out the causes of encephalitis or seizures.
What is rabies ? Rabies is caused by the rhabdoviridae ( family) , negative stranded RNA genome, lyssavirus. Rabies are the form of central nervous system infection of the mammals by rabies virus. Rabies are common in India, south America, Southeast Asia and africa . The reservoirs are foxes, dogs, bats, ( sliver haired /lasionycteris and eastern pipistrelle /pipistrellus bats are common reservoirs ), skunks, groundhogs, woodchucks and raccoons.
Rabies are most transmitted through saliva of infected host to uninfected animal by bitting. Other mode of transmission are bat aerosol exposure, abrasion , scratch, solid organ transplant and contact of saliva with mucous membrane. Virus is then transmitted via retrograde axoplasmic flow to the central nervous system. The virus will later multiply and replicate as well as disseminated and causing encephalitis.
References
1.ANDERSON, LARRY J., KARL G. NICHOLSON, ROBERT V. TAUXE, and WILLIAM G. WINKLER. “Human Rabies in the United States, 1960 to 1979: Epidemiology, Diagnosis, and Prevention.” Annals of Internal Medicine 100, no. 5 (May 1, 1984): 728–735. doi:10.7326/0003-4819-100-5-728.
2.Devriendt J, Staroukine M, Costy F, and Vanderhaeghen J. “Fatal Encephalitis Apparently Due to Rabies: Occurrence after Treatment with Human Diploid Cell Vaccine but Not Rabies Immune Globulin.” JAMA 248, no. 18 (November 12, 1982): 2304–2306. doi:10.1001/jama.1982.03330180064036.
3.Baltazard, M., and M. Ghodssi. “Prevention of Human Rabies.” Bulletin of the World Health Organization 10, no. 5 (1954): 797–803.
4.Wilde, Henry, Pakamatz Khawplod, Thiravat Hemachudha, and Visith Sitprija. “Postexposure Treatment of Rabies Infection: Can It Be Done Without Immunoglobulin?” Clinical Infectious Diseases 34, no. 4 (February 15, 2002): 477–480. doi:10.1086/324628.
Patient is admitted if developing symptoms and signs of rabies and encephalitis. The initial steps include assessment of the patient ‘s airway, breathing, circulation , disability and exposure. The affected area is wash thoroughly with soap, virucidal agent and water. The animal which bites the patient should be captured if possible for diagnosing the rabies. Tetanus immunization is considered.The affected domestic animal should be monitored for 10 days. Patient may not required secondary prophylaxis if animal caputred does not present with any symptoms and signs.
In case of wild animal, rabies should be tested if we able to catch the animal.Patient should be treated post exposure prophylaxis if the animal is failed to be captured. Post exposure prophylaxis is a proven treatment which is given to high risk individual.
Post exposure prophylaxis include passive immunization with human rabies immunoglobulin.20 IU/kg of human rabies immunoglobulin is required. Half of the dose is given intramuscularly while the other half of the dose is infiltrated around or at the wound.
Next consider immunization with active immunization of rabies vaccine. Avoiding vaccine administration to the gluteus due to administration to the subcutaneous fat. The active vaccine is administered into the thigh in children and deltoids in adult. There are few vaccines which include rabies vaccine adsorbed, human diploid vaccine intramuscularly and purified chick embryo cell vaccine. These vaccine also known as RabAvert, Imovax. If the patient had pre exposure prophylaxis and suffered from rabies infection consider vaccine booster on days 0 and 3. Passive immunization with human rabies immunoglobulin is avoided in this case.
In cases where the action to treat is delayed after exposure to rabies, consider administration of the vaccine as usual. Passive immunization with human immunoglobulin is not given.
Target groups such as foreign travelers in endemic areas, virus laboratory workers, animal handlers and veterinars may required pre exposure prophylaxis ( rabies vaccine on day 0, 7, 21, 28). Patient will be discharge if there is no evidence of rabies and the patient is stable. Patient should be followed and ensure the patient has adequate exposure to subsequent vaccine administered post exposure to rabies.
Patient may present with three manifestation of rabies which include paralytic dumb rabies ( 40%) which present as ascending paralysis that mimic Guillain Barre syndrome, encephalitis ( 80%) with persistent of neurological deficit and 1% of patient may suffer from sensory and motor deficit, seizure, myoclonus, choreiform movement and neuropathic pain.Rabies are presented with 5 stages. The stages are latent period, prodrome, encephalitis and coma which finally lead to death.
In latent period, the virus is incubated at the peripheral tissue. The latent period is around 1- 3 months. However it may last for a shorter period if it involves the bite to the neck or head.
The prodrome period is presented with nausea, vomiting, myalgia, fever, anorexia, malaise, headache and sore throat. Around the sited of the bite, the patient may also complain of fasciculation and paraesthesia. The prodrome period will last for 1- 7 days.
Patient may suffer from encephalitis, which include seizures, confusions, high fever, agitation, anxiety, deliriums and hallucinations. Besides that, patient may present with facial paralysis, diplopia, hydrophobia ( patient who try to swallow may suffer from violent involuntary contraction of the accessory muscle of the respiration, laryngeal, pharyngeal and diaphragmatic muscle. Patient may also suffer from pharyngeal spasm form air ( aerophobia). Myocarditis, autonomic instability ( dilated pupil, orthostatic hypotension, perspiration and hypersalivation) as well as dysrhythmias may also occur,
Besides that patient may suffer from flaccid paralysis, adult respiratory distress syndrome and inappropriate secretion of antidiuretic hormone. Patient will fall into coma and die if no pre or post exposure prophylaxis are given within 2 weeks.
The investigations require are full blood count, urea and electrolytes, creatinine, blood glucose, blood culture, urinalysis, saliva studies ( isolation of virus in cell culture, detection of rabies RNA by reverse transcriptase polymerase chain reaction) and serum ( detection of rabies on antibodies) as well as lumbar puncture ( to evaluate CSF which usually high in white blood cell, high in protein and normal level of glucose). Biopsy of the neck is considered. Further test such as immunofluorescent staining and reverse transcriptase polymerase chain reaction may also be considered. Chest x ray is useful to rule out possibilities of chest infection. CT scan is useful to rule out the causes of encephalitis or seizures.
What is rabies ? Rabies is caused by the rhabdoviridae ( family) , negative stranded RNA genome, lyssavirus. Rabies are the form of central nervous system infection of the mammals by rabies virus. Rabies are common in India, south America, Southeast Asia and africa . The reservoirs are foxes, dogs, bats, ( sliver haired /lasionycteris and eastern pipistrelle /pipistrellus bats are common reservoirs ), skunks, groundhogs, woodchucks and raccoons.
Rabies are most transmitted through saliva of infected host to uninfected animal by bitting. Other mode of transmission are bat aerosol exposure, abrasion , scratch, solid organ transplant and contact of saliva with mucous membrane. Virus is then transmitted via retrograde axoplasmic flow to the central nervous system. The virus will later multiply and replicate as well as disseminated and causing encephalitis.
References
1.ANDERSON, LARRY J., KARL G. NICHOLSON, ROBERT V. TAUXE, and WILLIAM G. WINKLER. “Human Rabies in the United States, 1960 to 1979: Epidemiology, Diagnosis, and Prevention.” Annals of Internal Medicine 100, no. 5 (May 1, 1984): 728–735. doi:10.7326/0003-4819-100-5-728.
2.Devriendt J, Staroukine M, Costy F, and Vanderhaeghen J. “Fatal Encephalitis Apparently Due to Rabies: Occurrence after Treatment with Human Diploid Cell Vaccine but Not Rabies Immune Globulin.” JAMA 248, no. 18 (November 12, 1982): 2304–2306. doi:10.1001/jama.1982.03330180064036.
3.Baltazard, M., and M. Ghodssi. “Prevention of Human Rabies.” Bulletin of the World Health Organization 10, no. 5 (1954): 797–803.
4.Wilde, Henry, Pakamatz Khawplod, Thiravat Hemachudha, and Visith Sitprija. “Postexposure Treatment of Rabies Infection: Can It Be Done Without Immunoglobulin?” Clinical Infectious Diseases 34, no. 4 (February 15, 2002): 477–480. doi:10.1086/324628.