An unusual case of fatal rabies encephalitis despite completing postexposure prophylaxis

Abstract

Rabies continues to be a major health scourge in many developing countries including India. It can be
effectively prevented by providing postexposure prophylactic treatment. Failure of Rabies postexposure
prophylaxis (PEP) is a rare occurrence. Our patient, a 39-year-old Male, was bitten by stray dog on the left
hand. It was Category III dog bite for which proper wound care and PEP 5 doses of antirabies cell culture
vaccine and Human Rabies Immunoglobulin was given. Two days after completing the 5th dose of PEP, he
presented with fever, neck rigidity, drooling of saliva, pain, and numbness in the left hand along with auditory
and visual hallucinations without hydrophobia and aerophobia. On 2nd say of hospitalization, he developed
progressive respiratory difficulty and decreased oxygen saturation for which he was intubated and put on
invasive ventilator support. However, he suffered fatal cardiac arrest and succumbed to his illness. Based
on his symptoms, a clinical diagnosis of febrile encephalopathy with differential diagnosis of acute rabies
encephalitis was made. On autopsy, his brain was markedly congested and histopathological examination
was suggestive of acute rabies encephalitis. However, no Negri bodies were seen. Further examination of
brain tissue by immunohistochemical labeling revealed numerous Negri bodies and confirmed the diagnosis
of rabies encephalitis.