Case: A 52 year old male was seen in outside emergency department (ED) for sudden radicular cervical pain for few days. He received cyclobenzaprine and was discharged. The next day he was admitted with diffuse tremors, fever and sweats. He received cyproheptadine and benzodiazepines for suspected serotonin syndrome and transferred to our facility. Exam noted an anxious person with diffuse coarse tremors, diaphoresis, temperature 39.8F, heart rate 113/min, and BP 153/105 mmHg. Blood counts and chemistries were normal except for Creatinine 1.29 mg/dl and Creatine kinase (CK) 1,475 units/L. He refused oral liquids and nasal oxygen for fear of choking. He was intubated and mechanically ventilated for hypoxia and paralyzed for worsening tremors and rising CK of 13,555 units/L. Brain MRI and EEG were unremarkable. CSF revealed a protein 72 mg/dl, glucose 119 mg/dl, WBC 8 cells/microliter (Lymphocytes 55%), RBC 7 cells/microliter. CSF HSV PCR and other viral studies were negative. Suspicion for rabies arose when worsening encephalitis was coupled with autonomic instability, hydrophobia and aerophobia. Family revealed that he lived in a trailer and wild life photography was a hobby. CSF, serum, saliva and skin biopsy samples were sent to the CDC. By day 7, he was in shock and required hemodialysis for anuric renal failure. On day 9, he was unresponsive with absent brainstem reflexes off sedation and paralytics. Repeat MRI Brain noted subdural fluid collections. EEG had generalized low voltage delta activity with minimal reactivity to noxious stimulation. On Day 11, the CDC reported RT-PCR positive for Rabies Virus in the full thickness skin biopsy from the nape of neck. Due to absent clinical improvement, medical futility and per family’s preference, life support was discontinued. The CDC confirmed rabies virus genome associated with Perimyotis subflavus (tri-colored bat).
Conclusion: Rabies is a fatal disease and diagnosis requires a high index of suspicion. This is the second case of Human Rabies in Missouri since 1959. Clinical manifestations may mimic hyperthermia syndromes such as serotonin syndrome.
V. S. B. Chinnakotla,
H. Sangha, None
W. Salzer, None
C. Rojas-Moreno, None