Journal of Postgraduate Medicine
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ARTICLE
 
 
Year : 1978  |  Volume : 24  |  Issue : 3  |  Page : 186-188  

Hydrophobia following antirabic prophylaxis - (A case report with a review of the literature)

S Maheshwari 
 Department of Preventive and Social Medicine, S.P.Medicle College, Bikaner, India

Correspondence Address:
S Maheshwari
Department of Preventive and Social Medicine, S.P.Medicle College, Bikaner
India

Abstract

A case of hydrophobia following sero-vaccine prophylaxis is reported. The probable reason was delayed and insufficient treat­ment of extensive severe facial wounds involving conjunctiva and/ or a failure on the part of sero-vaccine treatment.



How to cite this article:
Maheshwari S. Hydrophobia following antirabic prophylaxis - (A case report with a review of the literature).J Postgrad Med 1978;24:186-188


How to cite this URL:
Maheshwari S. Hydrophobia following antirabic prophylaxis - (A case report with a review of the literature). J Postgrad Med [serial online] 1978 [cited 2019 Aug 19 ];24:186-188
Available from: http://www.jpgmonline.com/text.asp?1978/24/3/186/42667


Full Text

 Introduction



The danger of dog bite has been recognized from antiquity with rabies as it dreaded end result. Aristotle knew th, disease and its association with dogs. Hi wrote in the 3rd century B.C., "Dog suffer from madness which nuts them ii a state of fury and all animals which the , bite, when in this condition, become also attacked with madness." [1] Celsus (A.D 30) described hydrophobia as "A most wretched disease in which the sick person is tormented at the same time by thirst and the fear of water and in which there is but little hope". [1] Although antirabies treatment (ART) if adequately carried out is usually effective, it does not always provide full protection against the disease in those cases which have either a very long or a very short incubation period.

Deaths due to hydrophobia after anti. rabies vaccine treatment (ARVT) are re­ported by many. [2],[4],[5],[13],[15],[16] It has been reported that failure rate in persons bitter by rabid animals is 7.7%, if we take into consideration all deaths; whereas it is 3.8% if only deaths occurring after 13 days of completing the treatment are con­sidered. [9] It is stated that approximately 3000, [15] 10000, [9] 15000 [14] cases of hydropho­bia occur every year in our country, and that an estimated 300 people die of rabies every year in India despite having taken all treatment. [15] Rates of treatment failure are not significantly different with nervous tissue and avianised vaccines. We are reporting below a case of hydrophobia following sero-vaccine prophylaxis.

 Case report



In this case, the anti-rabies vaccine used was nervous tissue, sheep brain, which was beta­propriolactone (BPL) inactivated and meant for human use and manufactured by Central Re­search Institute, Kasauli (H.P.). It is a 5% brain tissue with 025% Phenol and thiomersal. The vaccine was given, as recom­mended by the manufacturer"" for class III bite cases, i.e. subcutaneously over the anterior ab­dominal wall in dosage of 5 ml daily for 14 days only. The antirabic serum (ARS) used was re­fined horse globulin solution manufactured at C.R.I., Kasauli, each millilitre representing not less than 300 I.U. The dosage of ARS was as per recommendations of the manufacturer [12] i.e., 40 I.U. per Kilogram body weight; the patient being 60 Kg. in weight a total dose of 2400 I.U. was used. Half the quantity was used for local infiltration and dressing at the site of bite and half was injected intramuscularly in the gluteal region after a sensitivity test in the allergy out­door of the hospital.

The victim was a lady aged 66 years. She was bitten by a stray rabid dog over face on 13-9-75. There were multiple extensive and deep wounds with minor injury to the conjunctiva of the right eye. The dog was killed the next day. The wounds, (excluding the eye), were washed with water and chloroxylenol about 15 minutes after the bite. On 14-9-75 local as well as parenteral ARS was given, followed by a course of ARV without any interruption. She was given the first booster dose of the vaccine on 4-10-75; her final booster dose was due on 19-10­75. But, she was admitted in S.M.S. Hospital, Jaipur on 6-10-75 with the complaints of head­ache, uneasyness insomnia with pain and rigidity in neck followed by a clear cut fear for water the day after. She died on 12-10-75. The incubation period was 22 days. She survived for 6 days after the onset of the illness.

 Discussion



Strictly speaking a case could be con­sidered as treatment failure if at least 15 days have elapsed after the last injection of ARV, because production of antibodies start usually from the 10th day of starting ARVT. [3],[18] However, this patient was also given local as well as parenteral ARS on the day following the bite, which provides quick immunity lasting for about 2-3 weeks,

In such cases of treatment failure, a further dilemma could be whether death occurred because of hydrophobia or be­cause of a neuroparalytic reaction. A recently developed diagnostic test, the cor­neal impression smears, [4] would have been of immense value in arriving at an ante­mortem diagnosis of rabies in this case, but it could not be done because of want of facilities. Similarly, other confirmatory tests for rabies in the form of serum anti­body titre, Negri body test, animal innoculation, fluorescent antibody and virus isolation are required in certain cases to make the diagnosis. However, there were features in this case which favoured the diagnosis of hydrophobia. Thus, the clinical signs and symptoms of the patient were clearly in favour of hydrophobia; as she was given both ARS and ARV the chances of developing neuroparalytic reaction were probably smaller; the onset of neuroparalytic reac­tion is usually between 8-14 days of start­ing the vaccine treatment, [4] which was not observed in this case; the risk of fatality in neuroparalytic reactions has been re­ported to be from 0-40% by different workers. [7],[8],[10],[12],[17]

The case, therefore, falls into the cate­gory of sero-vaccine treatment failure. In laboratory mice, BPL sheep brain vaccine provides a maximum of 80% pro­tection against rabies. [11] The failure to protect in this case can be related to many causes such as (1) extensive deep facial wounds with conjunctival involvement; (2) the delayed local wound treatment sparing conjunctiva did not neutra­lise, kill or remove the virus suffi­ciently; (3) the virus might have fixed and travelled rapidly to the brain tissue due to short distance as viropexis takes place possibly in 5 minutes only; [6] (4) the interfering effects of ARS on the immu­nizing effects of ARV, (5) inadequacy of antibody preparation or refractoriness of the individual to antibody production; and (6) virulence of the street virus and potency of the vaccine at the time of use. In this case, the disease could possibly have appeared still earlier, as short an incubation periods as 10 days is report­ed, [8] but for the sero-vaccine treatment that the incubation period wsa lengthened and disease postponded.

Thus, even a full course of sero-vaccine treatment may fail to provide absolute protection against rabies in certain cases of bite by rabid animals, and that im­mediate efficient local wound treatment is a very important prophylactic measure. High risk cases for treatment failure are those of class III bite specially with injury to mucous membranes and in whom local wound treatment is neglected.

References

1Ahuja, M. L. and Brooks, A. G.: Hydro­phobia in India. Ind. Med. Gaz., 85: 449­453, 1950.
2Anderson, J. A. Daly, F. T. Jr. and Kidd, J. C.: Human rabies after anti­serum and vaccine post-exposure treat­ment. Ann. Int. Med. 64: 1297-1302, 1966.
3Baltazard, M.: Prevention of Human Rabies, Essai pratiqu du serum anti­rabique chez les mordus par loups enrages. Bulletin WHO, 13: 747-753, 1955.
4Bisseru, B.: "Rabies" 1st Edition, William Heinemann Medical Books Ltd., London, 1972.
5Brijkishore, Banerjee, S. C., Mahesh­wari, B. B., Gupta, R. D. and Gupta, M. C.: Antirabic prophylaxis follow-up in Agra. Ind. J. Preventive and Social Med., 4: 106-111, 1973.
6Carithers, H. A.: Mammalian bites of children. Amer. J. Dis. Child., 45: 150­156, 1958.
7Greenwood, M.: Quoted by Bisseru, B.4
8Harrison, T. R.. Adams. R. D., Bennett, I. L., Resnik, W. H., Thom, G. W. and Wintrobe, M. M.: "Principles of Inter­nal Medicine", 5th Edition. International student Edition, Kogakusha Co. Ltd., Tokyo, 1966.
9Jhala, H. I.: Rabies-S. N. Bhansali Lecture delivered at the Bombay Medical Union for the year 1969. Ind. J. Med. Sci. , 25: 53-60, 1971.
10Latimer, F. R.: Quoted by Bisseru. B.4
11Mathew, T., Raichowdhary, A. N., Bhola, S. R. and Toga, P. K.: Studies on BPL inactivated suckling Mouse Brain ARV, Paper presented in II National Seminar on "Zoonosis in India and their Control", Abstracts: 10-11, NICD, 16-22 June, 1977.
12Raichowdhary, A. N. and Thomas A. K.: "Principles and Practice of ART and control of Rabies", Central Research In­stitute, Kasauli. 1971.
13Sabeti, B.: Quoted by Bisseru B.4
14Satya, Prakash: Some Zoonotic Problems in India. Swasth Hind, 13: 135-137, 1969.
15Thomas, A. K.: Epidemiology of Rabies, Paper read in special committee to review the rabies research work I . C . M . R . , New Delhi, 1972.
16Veeraraghavan, N.: Annual Report of Director for the year 1966-67, Pasteur In­stitute of Southern India, Coonoor, 1969.
17Vijjajiva, A.: Quoted by Bisseru, B.4
18WHO: Expert Committee on Rabies; Technical Report Series No. 201, IV Re­port Geneva, 1960.

 
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