The unfortunate victim was a 73-year-old Haitian women. She initially went to an emergency room with a complaint of right shoulder pain, chest pain, headaches and high blood pressure. Difficulty swallowing was also noted when she was given pain medications, but she declined further testing and was discharged. It’s not surprising that rabies wasn’t considered at this point, although I doubt she was asked about animal contact or animal bites as a routine history question.
The next day, the woman went to two different emergency rooms, complaining of shortness of breath, spasms, hallucinations and balance problems. A cause was still not readily apparent, and over the next couple of days, her condition deteriorated, with development of more neurological abnormalities including tremors and mild seizures. Encephalitis (inflammation of the brain) was diagnosed, and a range of potential causes were ruled out. A nuchal skin biospy was collected for rabies testing but she was declared brain dead by the time results were obtained.
The strain of rabies that was identified most closely matched a canine rabies virus variant from a person in Florida who acquired rabies in 2004 while in Haiti. Upon further investigation, a cousin recalled that the person had been bitten by a dog in Haiti a few months earlier. The bite wasn’t considered severe and medical attention wasn’t sought.
As an almost invariably fatal infection but an almost completely preventable disease with proper medical care, education is a key aspect of rabies control, and that’s where most of the breakdowns occur. This person didn’t seek medical attention after the bite, because the bite wasn’t too severe. Unfortunately, mild bites can transfer rabies just like severe bites, and any bite needs to be investigated as a potential source of rabies, particularly in highly endemic areas.
Canine rabies is a major problem internationally, accounting for tens of thousands of human deaths each year. Canine rabies has been eradicated in the US, meaning the canine rabies virus strain is no longer circulating. That doesn’t mean dogs in the US can’t get rabies, since they can be infected with various wildlife strains, but there is not a circulating pool of canine rabies virus like in some other regions. Canine rabies is still endemic in Haiti, although there have been efforts to control it through education and vaccination of dogs and cats in the country (where less than 50% of dogs and cats are vaccinated).
People living and traveling to rabies-endemic regions like Haiti need to be aware of the potential risk of rabies and consider any dog bite a possible rabies exposure. Similarly, healthcare workers need to query animal exposure and animal bites as a routine practice, since as with this case, rabies can be hard to diagnose initially.