A case of an atypical course of rabies

Abstract

The aim of this study was to perform a clinical analysis of an atypical course of rabies in a 68-year-old female patient.

Materials and methods. A retrospective analysis of the medical records of the 68-year-old woman who died from the paralytic form of rabies was conducted. The patient was hospitalized at the Municipal Non-Profit Enterprise “Regional Infectious Diseases Clinical Hospital” of the Zaporizhzhia Regional Council from April 19 to April 29, 2024. The diagnosis of rabies was confirmed post-mortem by detection of rabies virus RNA in brain tissue using polymerase chain reaction (PCR), as well as by morphological verification of Babes–Negri inclusion bodies in the brain tissue.

Results. This clinical case describes an atypical (paralytic) form of rabies in the 68-year-old patient. The initial clinical presentation lacked classical manifestations such as agitation, aerophobia, and hydrophobia. The disease onset was characterized by flaccid paralysis, which progressively evolved into tetraparesis and other neurological signs indicative of encephalitic brain involvement. This atypical presentation significantly complicated the diagnostic process and resulted in the establishment of only symptomatic diagnoses during life. Suspicion of rabies arose only after clarification of the epidemiological history, which revealed that 2–3 months before the onset of symptoms the patient had been bitten by a dog of unknown vaccination status that died two days after the incident. Definitive confirmation of rabies was obtained during the post-mortem pathological examination through detection of rabies virus RNA in brain tissue using PCR and identification of Babes–Negri inclusion bodies. In our opinion, the most likely cause of infection and the atypical disease course was the administration of an incomplete course of post-exposure rabies prophylaxis. This observation highlights the critical importance of strict adherence to the anti-rabies prophylaxis protocols recommended by the World Health Organization.

Conclusions. This clinical case demonstrates that an atypical (paralytic) course of rabies may mimic other neurological syndromes, particularly in the absence of a clearly established epidemiological history. Such circumstances pose significant challenges to timely and accurate diagnosis. Incomplete post-exposure rabies prophylaxis was identified as the cause of the fatal outcome and is considered the probable reason for the atypical clinical course of the disease.