Clinical features

• Incubation 4 days to several years (usually a few months)

• Virus spreads from wound along nerve axons to reach CNS causing fatal encephalitis (death in 1-7 days)

• Furious (more common): hyperactivity, confusion, hallucinations, hydrophobia

• Paralytic: drowsiness, flaccid paralysis, pain, fasciculations

• Autonomic hyperactivity e.g. hypersalivation, lacrimation, BP, cardiorepsiratory arrest

Diagnosis

• PCR (saliva/skin biopsy), virus isolation (saliva, brain, CSF), immunofluorescence of viral antigen (skin punch biopsies). Neutralising antibody response absent/delayed

Treatment

• Palliative

• Milwaukee protocol (cocktail of antiviral, intensive care) ? Only for early encephalitis with American bat rabies

Prevention

• Dog vaccination

Post-exposure Prophylaxis (PEP)

• Clean wound + anti-tetanus toxoid +/- antibiotics

• Vaccine. Standard 5-dose IM method days 0, 3, 7, 14, 28 ( days 0 and 3 if had vaccine pre-exposure)

Category 1

• None

Category 2

• Minor

Category 3

• Severe

• Rabies immunoglobulin into wounds for major exposure

Pre-Exposure rabies vaccination

• Days 0, 7, 28