864. Therapeutic Immunosupression to Treat Rabies Encephalitis
Session: Oral Abstract Session: Pushing the Envelope in CNS Infections
Thursday, October 4, 2018: 2:00 PM
Room: S 158

Background:

Rabies is nearly universally fatal with about 60000 annual deaths globally; <0.1% cases survive. Reports of therapeutic coma leading to survival are outnumbered by reports of failure. Based on personal discussions with a leading rabies expert (Dr Rodney Willoughby), we hypothesized that limiting CNS immune response based on CSF antibody titre (ABT) might prove useful. We report on successful use of immunosuppression in 1 patient.

Methods:

A 26 year old male was admitted with 2 day history of flu like syndrome. He had category III dog bite on face 17 days prior. RIG was not given due to non-availability; he had received ARV day 0, 3, 7 & 14 on time.

On 4th day of admission (day 0), neurological features started - difficulty in walking & diplopia; hydrophobia was noted. Working diagnosis of rabies was made. MRI brain on day 1 showed subtle abnormal T2 & flair hyper intensities in pons, medulla, & left hippocampus. CSF (day 1) showed 105 cells; all lymphocytes. The RFFIT serum & CSF ABTs & rabies PCRs are tabulated below. Since ADEM was a possibility, he was begun on IVIg. Work up for other viral encephalitis was negative. Repeat CSF ABT on day 6 confirmed rabies. Postulating risk of death due to cerebral edema due to CNS immune response, dexamethasone (dexa) 6mg/kg/day in 4 divided doses was begun on day 8. Serial MRI & CSF were done. Dexa taper was done based on MRI & CSF ABT. Intensive supportive care was given.

Results:

MRI on day 9 & day 12 showed no cerebral edema. Dexa taper was started from day 13 by half every alternate day; it was given till day 28.

By day 17, there was intermittent eye opening, withdrawal to pain & some orofacial & limb movements. Further recovery had waxing & waning course. Now he is nearly 1 year post rabies encephalitis. He is unable to talk or comprehend, but can sit independently & is able to walk with support.

Conclusion:

Immunosuppressive therapy with dexa to improve outcomes in rabies seems an exciting option. Optimal dose, time of start, & taper schedule need further studies. CSF ABT based tapering appears promising. Larger studies with this approach are needed.

Table 1

Day

1

3

6

13

17

20

55

Serum ABT

2048

X

8192

32768

16384

16384

8192

CSF ABT

64

X

1024

8192

X

4096

4096

Saliva PCR

Negative (Neg)

X

Neg

X

X

X

X

CSF PCR

Neg

X

Neg

X

X

X

X

Nuchal biospy

x

Neg

x

X

X

X

X

Divyashree S, MD1, Archana Shrivastava, MD2, Tushar Sontakke, MD2 and Anil Venkitachalam, MD, DM3, (1)Dept of Infectious Diseases, MGM New Bombay Hospital, Navi Mumbai, India, (2)Department of Critical Care, MGM New Bombay Hospital, Navi Mumbai, India, (3)Department of Neurology, MGM New Bombay Hospital, Navi Mumbai, India

Disclosures:

D. S, None

A. Shrivastava, None

T. Sontakke, None

A. Venkitachalam, None

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