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BITE/RABIES
Introduction
Acute
viral
disease
that
causes
fatal
encephalomyelitis
(incurable
disease)
ssRNA
Virus,
Lyssavirus
genus
of
the
Rhabdoviridae
family.
Transmitted
through
rabid
animals
saliva
following
bites,
scratches,
licks
on
broken
skin
and
mucous
membrane
In
India,
majority
of
disease
transmission
is
via
dogs
(97%)
Development
of
rabies
can
be
prevented
if
animal
bites
are
managed
appropriately
Pathophysiology
From
the
wound
of
entry,
the
rabies
virus
travels
along
the
peripheral
nerves.
The
retrograde
axonal
transport
of
the
rabies
virus
to
the
CNS
is
the
key
step
of
pathogenesis
during
natural
infection.
From
the
CNS,
the
virus
further
spreads
to
other
organs.
The
salivary
glands
located
in
the
tissues
of
the
mouth
and
cheeks
receive
high
concentrations
of
the
virus,
thus
allowing
it
to
be
further
transmitted
through
saliva.
Infected
animal
bite
saliva
containing
infectious
rabies
virus
is
deposited
in
tissues
virus
binds
to
the
nicotinic
acetylcholine
receptors
in
the
muscles
spreads
across
the
motor
end
plate
and
ascends
and
replicates
along
peripheral
nervous
axoplasm
to
the
dorsal
root
ganglia
(DRG),
and
the
central
nervous
system
(CNS)
eventually
the
virus
spreads
outward
by
peripheral
nerves
to
all
the
tissues
and
organ
systems.
The
risk
of
developing
rabies
following
a
bite
or
scratch
by
a
rabid
animal
depends
on
the
type
of
wound
(bite
or
scratch),
the
number
of
bites,
the
depth
of
the
bites,
and
the
location
of
the
wounds
Clinical
Features
Incubation
Period:
20-90
days
(shorter
IP
when
bite
is
on
the
head
than
when
it
is
on
an
extremity)
Local
pain
Stages
of
the
disease:
1. Prodromal:
Pain,
paresthesia,
headache,
fever,
nausea
and
vomiting,
anorexia
2. Acute
Neurologic
Phase:
Anxiety,
agitation,
depression,
paresthesia,
incoordination,
hyperactivity,
confusion,
hydrophobia,
hyperventilation,
aphasia
3. Coma:
hypotension,
hypoventilation,
pituitary
dysfunction,
arrhythmias,
death
Diagnosis
WHO
definition:
An
acute
neurological
syndrome
dominated
by
forms
of
hyperactivity
(furious
rabies)
or
paralytic
syndrome
(dumb
rabies)
progressing
towards
coma
and
death,
usually
by
cardiac
or
respiratory
failure,
typically
within
7-10
days
of
onset
of
symptoms.
Several
tests
are
necessary
to
diagnose
rabies
ante-mortem
(before
death)
in
humans;
no
single
test
is
sufficient.
Secretions
(saliva,
spinal
fluid),
skin
biopsies
of
hair
follicles,
nape
of
neck
can
be
used
to
diagnose
rabies.
Gold
Standard
is
DFA
(direct
fluorescent
antibody)
&
in
HPE:
Presence
of
Negris
bodies
is
variable
MANAGEMENT
Categories
of
Exposure
Category
Type
of
contact
I
Recommended
Post
Exposure
Prophylaxis
Touching or feeding of animals, Licks on None, if reliable case
intact skin, Contact of intact skin with
history is available
secretions / excretions of rabid animal
/human case
II
Nibbling of uncovered skin, Minor
scratches or abrasions without bleeding
Single or multiple transdermal bites or
scratches, licks on broken skin
Contamination of mucous membrane with
saliva (i.e. licks)
III
Wound management
Anti-rabies
vaccine
(ARV)
Wound management
Anti-rabies
vaccine
(ARV)
Rabies immunoglobulin
(RIG)
Note:
Pregnancy,
lactation,
infancy,
old
age
and
concurrent
illness
are
not
contra
indications
for
rabies
PEP
in
the
event
of
an
exposure.
1. Wound
Care
This
is
the
priority
Do
ASAP
with
running
water,
use
soap
and
disinfectant
Do
it
even
if
the
patient
presents
late
Avoid
direct
touching
of
the
wound
Local
infiltration
with
RIG
(in
Cat
III,
in
immunocompromised
->
Cat
II
and
III)
Tetanus
prophylaxis
Suturing
Avoid
as
far
as
possible
Antibiotics
(Augmentin
for
3-5
days)
2. Rabies
Vaccine
(Active
Immunisation,
only
for
Cat
II
and
III
exposures)
Same
dose
and
number
of
injections
regardless
of
age/TBW
a.
Key
Points
Know
the
categories
of
dog
bite
and
treat
accordingly.
Convert
Preexposure
prophylaxis
to
Postexposure
if
the
animal
stays
healthy
after
10
days
of
observation.
(0,3,7,28)
Administer
RIG
only
in
Cat
III
but
in
immunocompromised,
give
RIG
in
both
Cat
II
and
III.
No
skin
testing
is
recommended
before
giving
RIG,
Adverse
effects
are
rare.
Note:
This
document
represents
the
treatment
of
dog
bite
as
per
the
National
Guidelines
in
India.
For
Further
Reading:
1. http://www.ncdc.gov.in/Rabies_guidelines2014.pdf
2. http://www.who.int/rabies/PEP_prophylaxis_guidelines_June10.pdf
3. http://www.cdc.gov/rabies/exposure/index.html
4. http://www.who.int/bulletin/volumes/92/4/14-136044/en/
Thanks!
Questions/Comments/Feedback
Lakshay
Chanana
drlakshay_em@yahoo.com
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