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Human rabies in the US (technical, but perhaps of interest)



 
 
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  #1  
Old August 13th 05, 04:15 PM
Howard C. Berkowitz
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Posts: n/a
Default Human rabies in the US (technical, but perhaps of interest)

RABIES, HUMAN - USA 1990-2004
*****************************
A ProMED-mail post
http://www.promedmail.org
ProMED-mail is a program of the
International Society for Infectious Diseases
http://www.isid.org

Sponsored in part by Elsevier, publisher of
Infectious Disease products
http://www.intl.elsevierhealth.com/infectiousdiseases/

Date: Thu 11 Aug 2005
From: ProMED-mail
Source: Morbidity and Mortality Weekly Report, Fri 12 Aug 2005
/54(31);767-769
[edited]
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5431a2.htm


USA: Human Rabies -- Florida, 2004 (ex Haiti)
- ---------------------------------------------
Rabies is a viral infection of the central nervous system, usually
contracted
from the bite of an infected animal, and nearly always fatal without
postexposure prophylaxis (1). In February 2004, a man aged 41 years died
after
a 4-day hospitalization in Broward County, Florida. A diagnosis of
rabies was
considered on the day before the patient's death; however, no antemortem
samples were obtained for testing. In March 2004, postmortem samples of
fixed
brain material were sent to CDC, where laboratory testing confirmed a
diagnosis of rabies, the 47th case of human rabies reported in the
United
States since 1990 (CDC, unpublished data, 2005). This report summarizes
results of the subsequent investigation led by the Broward County Health
Department and laboratory testing at CDC, which determined that the
rabies
virus was a canine variant present in Haiti, where the man had traveled
and
reportedly been bitten by a dog. Rabies should be considered in persons
after
a dog bite, especially if the bite occurs in a country where canine
rabies is
enzootic.

The man arrived at the hospital emergency department with a 2-day
history of
dysphagia accompanied by hyperventilation and agitation when he
attempted to
swallow liquids. The problem had worsened by the time of admission; he
was
noted as "almost phobic" to liquids. The patient reported having a brief
period of mild fever. He was able to swallow soft, solid food and did
not
complain of throat pain or discomfort. Upon physical examination of his
mouth
and throat, the patient became agitated and experienced
hyperventilation. He
was admitted for further observation and diagnostic evaluation. On the
day of
admission, a neurology consultant concluded that the dysphagia etiology
was
unknown and recommended infectious disease, gastrointestinal, and
pulmonary
consultations. Examination results by a gastrointestinal consultant on
the
same day were unremarkable, except for dysphagia and phobia to liquids.

The patient reported a history of malaria and ureteral stricture and
surgery.
Magnetic resonance imaging study results were unremarkable. Results of
examinations of the patient's ear, nose, and throat, including a swallow
test
(i.e., cervical esophagram), and radiographs of neck and soft tissue
were
normal. Because examination elicited substantial agitation and
hyperventilation in the patient, anti-anxiety medical management was
instituted, and the patient was referred for psychiatric evaluation On
his 3rd
day of hospitalization, the patient had a consistent fever of 103 F
(39.4 C)
and an elevated white blood cell count of 14.5/microL (normal: 3.6 to
11.0/microL). An infectious disease consultant recommended a lumbar
puncture
and testing for viral illness, especially rabies. The patient's wife
reported
that her husband had been bitten on the fingertip by a dog 8 months
earlier
while he was visiting Haiti. The wife reported that the dog was still
alive;
however, that could not be confirmed by investigators. She said her
husband
had not traveled back to Haiti during the interim. Anti-malarial
treatment of
the patient also was empirically initiated pending the results of
malaria
testing.

On the 4th day of hospitalization, the patient experienced diplopia and
was
decreasingly responsive. He went into cardiopulmonary arrest and died.
Antemortem rabies testing was under consideration, but the patient died
before
samples were collected. On histopathologic examination of the cerebral
cortex,
pons, hippocampus, and spinal cord, the medical examiner described
cytoplasmic
inclusions consistent with Negri bodies. Unstained slides of
formalin-fixed
samples of brain material were sent to CDC for diagnosis and typing.
Rabies
virus antigen was detected by a modification of the direct fluorescent
antibody test (2). A reverse transcription-polymerase chain reaction
assay
produced an amplicon sequence that was compatible with a canine rabies
virus
variant present in Haiti. This variant has not been documented among
domestic
or wild animal reservoirs in the United States. One close family member
underwent postexposure prophylaxis for exposure to the patient's
secretions.

MMWR Editorial note
- -------------------
Of the 47 cases of human rabies reported in the United States since
1990, 4
occurred in organ transplant recipients and were associated with an
undetected
case of rabies in a single organ donor (3); the remainder apparently
were
acquired from contact with animals with rabies virus infections. 38 (81
percent) of the infections were acquired in the United States. Among the
9
infections acquired elsewhere, 2 were acquired in Haiti (the 2004 case
described in this report and a 1994 case), 2 in Mexico (1993 and 1994),
and
one each in India (1992), Southeast Asia (1996), Ghana (2000), the
Philippines
(2001), and El Salvador (2004).

The greatest risk for naturally acquired rabies in the United States is
from
encounters with and bites from insectivorous bats (4). In particular, a
rabies-
virus variant associated with 2 small-bodied bats, the eastern
pipistrelle bat
(_Pipistrellus subflavus_) and silver-haired bat (_Lasionycteris
noctivagans_)
was identified in 20 (69 percent) of 29 persons with samples tested.

Human rabies is preventable if the exposure is recognized and the
patient
receives appropriate wound care and postexposure prophylaxis before
clinical
signs of rabies are evident. Postexposure prophylaxis consists of rabies
immune globulin infiltrated at the site of the exposure and 1 dose of
rabies
vaccine administered in the deltoid (or anterolateral thigh of infants
and
small children) on days 0, 3, 7, 14, and 28 (1). When applied
appropriately,
this combination has been effective in preventing death after an
exposure.

However, the continued availability of rabies vaccine currently relies
upon
only one licensed manufacturer in the United States; a 2nd manufacturer
suspended and has not resumed production after a voluntary recall of its
rabies vaccine in March 2004 (5).

In the United States, mandatory vaccination and stray-dog control
programs
have virtually eliminated circulation of any canine rabies virus variant
among
dogs (6). In comparison, occurrence of rabies in dogs remains a problem
in
Haiti and other developing countries (7). Because of the risk for rabies
exposure in these countries, travelers are advised to avoid contact with
dogs
and other animals, and rabies pre-exposure prophylaxis (consisting of 3
intramuscular doses of rabies vaccine on days 0, 7, and 21 or 28) is
recommended for persons planning to stay longer than 30 days in remote
areas
without access to medical facilities (1). The patient described in this
investigation reportedly was bitten by a dog in Haiti 8 months before
clinical
signs of rabies became evident. This was the longest incubation period
among
12 U.S. rabies cases with exposure history reported since 1997 (median:
39
days; range: 21 to 240 days); however, longer incubation periods of 11
months
to 6 years were suggested by findings in 3 cases previously described
(8).

Although human rabies is rare in the United States, it should be
considered in
the postmortem differential diagnosis of fatal viral encephalitis cases
with
short morbidity periods if no cause of disease has been established.
Hospitalized patients with encephalitis of unknown etiology should be on
contact precautions, and rabies should be part of antemortem
differential
diagnosis in these patients. Both antemortem and postmortem testing for
rabies
are available at CDC and can be arranged through state health
departments.
Antemortem diagnostic samples consist of a full-thickness skin biopsy (4
to 6
mm in diameter) from the nape of the neck, fresh saliva, serum, and
cerebrospinal fluid. Although postmortem rabies diagnosis can be
performed on
formalin-fixed brain material, fresh brain material provides the optimal
sample for maximum sensitivity, specificity, and time efficiency.

With the recent report from Wisconsin of a survivor of clinical rabies
(9),
rapid diagnosis of rabies is even more critical to managing a patient's
clinical course, despite a poor prognosis. In addition to enabling
consideration of novel interventions, advantages of early diagnosis
include
prompt implementation of appropriate infection-control measures, thereby
limiting the number of persons exposed or potentially exposed who
require
postexposure prophylaxis. Retrospective detection of 4
transplant-associated
rabies cases (3) and retrospective identification of an additional case
in
California in an immigrant from El Salvador, brought the total number of
2004
cases in the United States to eight, the highest number of human rabies
cases
reported since 1956, when 10 cases were reported.

References
- -----------
(1) CDC. Human rabies prevention--United States, 1999: recommendations
of the
Immunization Practices Advisory Committee (ACIP). MMWR 1999;44(No. RR-1).

(2) Warner CK, Zaki SR, Shieh WJ, et al. Laboratory investigation of
human
deaths from vampire bat rabies in Peru. Am J Trop Med Hyg 1999;60:502--7.

(3) CDC. Update: investigation of rabies infections in organ donor and
transplant recipients--Alabama, Arkansas, Oklahoma, and Texas, 2004.
MMWR
2004;53:615--6.

(4) CDC. Human death associated with bat rabies--California, 2003. MMWR
2004;53:33--5.

(5) CDC. Manufacturer's recall of human rabies vaccine--April 2, 2004.
MMWR
2004;53:287--9.

(6) Krebs JW, Mandel EJ, Swerdlow DL, Rupprecht CE. Rabies surveillance
in the
United States during 2003. J Am Vet Med Assoc 2004;225:1837--49.

(7) World Health Organization. Rabnet. Geneva, Switzerland: World Health
Organization; 2005. Available at
http://gamapserver.who.int/globalatlas/home.asp.

(8) Smith JS, Fishbein DB, Rupprecht CE, Clark K. Unexplained rabies in
three
immigrants in the United States: a virologic investigation. N Engl J Med
1991;324:205--11.

(9) CDC. Recovery of a patient from clinical rabies--Wisconsin, 2004.
MMWR
2004;53:1171--3.

(10) Willoughby RE Jr, Tieves KS, Hoffman GM, et al. Survival after
treatment
of rabies with induction of coma. N Engl J Med 2005;352: 2508--14.

- --
ProMED-mail


[This report provides an excellent review of rabies virus infection in
the USA
in recent years. The continuing lack of awareness of the hazard and the
failure of travellers to rabies-endemic areas to take adequate
precautions for
their own protection are matters of concern -- as is the decline in
vaccine
production. - Mod.CP]

[ProMED has posted 36 reports of rabies in humans in the USA since 1995.
Those interested should search the ProMED website, www.promedmail.org,
using
the search words rabies, USA & human in the Title. - Mod.JW]

[Elsevier reference:
C. Sriaroon et al. 2005. Common dilemmas in managing rabies exposed
subjects.
Travel Medicine & Infectious Disease 3(1)1-7.
http://dx.doi.org/10.1016/j.tmaid.2004.05.003]
  #2  
Old August 14th 05, 07:01 AM
external usenet poster
 
Posts: n/a
Default

Howard C. Berkowitz wrote:
RABIES, HUMAN - USA 1990-2004
*****************************
A ProMED-mail post
http://www.promedmail.org
ProMED-mail is a program of the
International Society for Infectious Diseases


Seems so sad. My first impression was of unbelievable incompetence.

Did it say it was in Broward County in Florida where this happened?
Is that not one of the counties where they miscounted the votes
or votes not done properly - and Bush was elected, well, chosen
by the Supreme Court as a result?

I always thought that the classic symptom of rabies was fear
of water, of liquids, which this man had. Not common knowledge?

The report makes it all seem so casual. The infectious disease
specialist says to check for rabies and why are they taking
their time? He's dead by the next day! Check for rabies is like
checking for bubonic plague, it's not a causal affair.

It's scary. This sort of lackadaisical incompetence I see a lot
of even in big northern cities with so-called world-class
medical centers.

But the water phobia, that's a dead giveaway for rabies, is it not?

  #3  
Old August 15th 05, 04:26 AM
external usenet poster
 
Posts: n/a
Default

Cheryl Perkins wrote:
A lot of the time when I read of some mistake, even a fatal one, I think
'There but for the grace of God go I', because I've made a lot of mistakes
in my times, and one or to might have been fatal, if I hadn't been lucky.
Not medical mistakes; I'm not a medical professional. But in spite of all
their training, they're still human, even the best of them.

--
Cheryl


I'll grant you that they are human, barely, but incompetent I still
well,
scream. How incompetent? Unbelievably incompetent, and I am talking
Ivy League, board certified doctors. I think I should publish an
article.
To wit, I noticed about 10 cardiologists, at least, in fact, every
single
cardiologist at the University of Pennsylvania miss a heart attack in
an
electrocardiogram, even after it was pointed out to them! Now how
incompetent
is that? And it just starts. I think this should be written up while I
still
have access to the critical records before they are "lost."

My experience has been that "doctors" are worse than useless. I would
opt for scientists, highly trained technicians and computers. If you'd
like, I could go on how all these doctors missed atrial fibrillation,
a potentially dangerous arrhythmia, until it was pointed out to them
by myself!

Where do I write these things up? A cat newsgroup is not quite visible
not quite the relevant place, except I have met vets who are as
incompetent, but what, that's enough!

  #5  
Old August 15th 05, 03:57 PM
Howard C. Berkowitz
external usenet poster
 
Posts: n/a
Default

In article , Cheryl Perkins
wrote:

wrote:
snip
I always thought that the classic symptom of rabies was fear
of water, of liquids, which this man had. Not common knowledge?


I thought so.

The report makes it all seem so casual. The infectious disease
specialist says to check for rabies and why are they taking
their time? He's dead by the next day! Check for rabies is like
checking for bubonic plague, it's not a causal affair.


It's scary. This sort of lackadaisical incompetence I see a lot
of even in big northern cities with so-called world-class
medical centers.


But the water phobia, that's a dead giveaway for rabies, is it not?


No, it doesn't happen in all cases.


I don't know. There are probably other conditions which result in
hydrophobia. And they train doctors to think of horses, not zebras, when
they hear hoofbeats. In other words, not to be distracted from the
obvious
by the possibility of something really rare. I'm a bit ambivalent about
stuff like this. Some doctors are clearly and provably incompentant, but
all of them are human, and all of them miss things sometimes. Not doing
the rabies test immediately does sound odd, but there could be reasons
for that, too, I don't expect it's the kind of thing they can do instantly
for
instant results. And the results wouldn't have made a bit of difference.


The rules for treatment are to start it immediately if the animal can't
be found, if the animal is killed and the brain examined, or an animal
under observation starts to show symptoms.

Isn't it impossible, or very nearly so, to survive rabies once the
symptoms are obvious? I think one person has done so in all of history.


IIRC, there's one definite survivor who received none of the preventive
treatment. There are a slightly larger number, probably under 10, who
survived after getting the treatment late.

You have to have the treatment right after the injury; in fact, I think
they start the treatment before they had the suspect animal tested.


Correct, especially when they don't have the suspect animal. They will
typically observe a pet with a current rabies immunization for 10 days,
and, if there are no symptoms, not treat at all, and hopefully return
the animal to its home.


A lot of the time when I read of some mistake, even a fatal one, I think
'There but for the grace of God go I', because I've made a lot of
mistakes
in my times, and one or to might have been fatal, if I hadn't been lucky.
Not medical mistakes; I'm not a medical professional. But in spite of all
their training, they're still human, even the best of them.

  #6  
Old August 15th 05, 04:00 PM
Howard C. Berkowitz
external usenet poster
 
Posts: n/a
Default

In article , John F.
Eldredge wrote:

On Sun, 14 Aug 2005 11:21:05 +0000 (UTC), Cheryl Perkins
wrote:

wrote:
snip



Also, I seem to remember reading that, by the time the symptoms show
up, it is usually too late to save your life. This is why rabies
vaccine is used as a precaution whenever it is suspected, but can't be
proven, that someone was exposed to rabies.


There are actually several immune preparations. The true vaccine is for
people at high risk, such as veterinarians and vet techs, people
traveling in areas with lots of wild dogs, etc.

The treatment gives the patient extra antibodies to fight the virus, but
does not itself confer immunity.


Plague (as in the Black Death of 14th-century Europe) is another
disease that most people wouldn't necessarily think of being a risk,
but it is endemic in the Southwest USA, and every year some people die
from it. It is primarily a disease of rodents, but if you come into
contact with an infected flea, either through direct contact with an
infected rodent or through the flea transferring to your pet, and from
there to you, you can catch the disease. It is curable with
antibiotics if diagnosed soon enough.


Competent physicians in the Southwest should think of it.

Correct. Incidentally, cats carrying the fleas, and themselves infected,
respond well to antibiotics. It shouldn't be a death sentence for either
the human or the cat.
  #7  
Old August 15th 05, 04:13 PM
Howard C. Berkowitz
external usenet poster
 
Posts: n/a
Default

In article .com,
wrote:

Cheryl Perkins wrote:
A lot of the time when I read of some mistake, even a fatal one, I
think
'There but for the grace of God go I', because I've made a lot of
mistakes
in my times, and one or to might have been fatal, if I hadn't been
lucky.
Not medical mistakes; I'm not a medical professional. But in spite of
all
their training, they're still human, even the best of them.

--
Cheryl


I'll grant you that they are human, barely, but incompetent I still
well,
scream. How incompetent? Unbelievably incompetent, and I am talking
Ivy League, board certified doctors. I think I should publish an
article.


If you have hard data, there are any number of medical journals, medical
reporters, or professional mailing lists that may be appropriate. If
it's in a specific locality, the relevant medical society may be
interested, or a national organization such as the American College of
Cardiology. If it's a hospital, the data should be brought to the
attention of their risk management group.

To wit, I noticed about 10 cardiologists, at least, in fact, every
single
cardiologist at the University of Pennsylvania miss a heart attack in
an
electrocardiogram, even after it was pointed out to them! Now how
incompetent
is that?


I'm not sure how to respond to that. The electrocardiogram is not
necessarily abnormal in heart attacks; a substantial number do not show
Q waves, and others will have a normal ST segment. I have controlled
angina, and, with studies such as SPECT, angiography, and Biosense
electrical mapping, have had some minor and probably unnoticed infarcts.
Through all of this, my ST segment has been isoelectric.

What specific abnormality did they miss, and was it picked up by the
analysis program?

On an emergency basis, the ECG alone is not enough. It should be
cross-checked with blood tests for cardiac enzymes (usually CK-MB is
enough), troponins, and possibly C-reactive protein. Remember that a
patient presenting with chest pain, and having real disease, may have
something completely different than a heart attack (myocardial
infarction) such as pericarditis, pleurisy, etc. A chest X-ray and
possibly ultrasound are appropriate here, as may other tests depending
on the presentation. A few examples here could be arterial blood gasses,
comprehensive metabolic panel ("Chem-24"), complete blood count with
differential, amylase and lipase, etc.

Physical examination, history, and observation are all important. In
many cases, it's hard to differentiate between angina (myocardial
ischemia) and myocardial infarcts. If the pain goes away quickly, it can
be appropriate to monitor for 48 hours or so, and, if there are no
symptoms, release with followup. That followup may require stress
testing with ultrasound or SPECT nuclear scans, rather than relying on
the ECG.


And it just starts. I think this should be written up while I
still
have access to the critical records before they are "lost."

My experience has been that "doctors" are worse than useless. I would
opt for scientists, highly trained technicians and computers. If you'd
like, I could go on how all these doctors missed atrial fibrillation,
a potentially dangerous arrhythmia, until it was pointed out to them
by myself!


What were the circumstances? AF usually has visible symptoms as well as
ECG abnormalities.


Where do I write these things up? A cat newsgroup is not quite visible
not quite the relevant place, except I have met vets who are as
incompetent, but what, that's enough!

That depends on whether you are dealing with individual physicians, a
specific group, or something else.
  #8  
Old August 16th 05, 04:52 AM
external usenet poster
 
Posts: n/a
Default


Howard C. Berkowitz wrote:
In article .com,
wrote:

Cheryl Perkins wrote:
A lot of the time when I read of some mistake, even a fatal one, I
think
'There but for the grace of God go I', because I've made a lot of
mistakes
in my times, and one or to might have been fatal, if I hadn't been
lucky.
Not medical mistakes; I'm not a medical professional. But in spite of
all
their training, they're still human, even the best of them.

--
Cheryl


I'll grant you that they are human, barely, but incompetent I still
well,
scream. How incompetent? Unbelievably incompetent, and I am talking
Ivy League, board certified doctors. I think I should publish an
article.


If you have hard data, there are any number of medical journals, medical
reporters, or professional mailing lists that may be appropriate. If
it's in a specific locality, the relevant medical society may be
interested, or a national organization such as the American College of
Cardiology. If it's a hospital, the data should be brought to the
attention of their risk management group.

To wit, I noticed about 10 cardiologists, at least, in fact, every
single
cardiologist at the University of Pennsylvania miss a heart attack in
an
electrocardiogram, even after it was pointed out to them! Now how
incompetent
is that?


I'm not sure how to respond to that. The electrocardiogram is not
necessarily abnormal in heart attacks; a substantial number do not show
Q waves, and others will have a normal ST segment. I have controlled
angina, and, with studies such as SPECT, angiography, and Biosense
electrical mapping, have had some minor and probably unnoticed infarcts.
Through all of this, my ST segment has been isoelectric.

What specific abnormality did they miss, and was it picked up by the
analysis program?

On an emergency basis, the ECG alone is not enough. It should be
cross-checked with blood tests for cardiac enzymes (usually CK-MB is
enough), troponins, and possibly C-reactive protein. Remember that a
patient presenting with chest pain, and having real disease, may have
something completely different than a heart attack (myocardial
infarction) such as pericarditis, pleurisy, etc. A chest X-ray and
possibly ultrasound are appropriate here, as may other tests depending
on the presentation. A few examples here could be arterial blood gasses,
comprehensive metabolic panel ("Chem-24"), complete blood count with
differential, amylase and lipase, etc.

Physical examination, history, and observation are all important. In
many cases, it's hard to differentiate between angina (myocardial
ischemia) and myocardial infarcts. If the pain goes away quickly, it can
be appropriate to monitor for 48 hours or so, and, if there are no
symptoms, release with followup. That followup may require stress
testing with ultrasound or SPECT nuclear scans, rather than relying on
the ECG.


You know what, Howard? In my (most humble and largely uneducated)
opinion, sometimes the cardiac tests are worthless. I mean specifically
for diagnosing blockage, not an actual heart attack. I've had stress
tests, thalium tests, chest ex-ray, all the bloodwork, etc. etc. and
was pronounced fit as a fiddle. Until a cath was done. I realize
doctors don't routinely perform those, they carry risk and are
extremely expensive too, but IMO it's the only thing that really shows
what's going on in there.
Just my .02.

Sherry

  #9  
Old August 16th 05, 07:19 PM
Howard C. Berkowitz
external usenet poster
 
Posts: n/a
Default

In article .com,
wrote:

You know what, Howard? In my (most humble and largely uneducated)
opinion, sometimes the cardiac tests are worthless. I mean specifically
for diagnosing blockage, not an actual heart attack. I've had stress
tests, thalium tests, chest ex-ray, all the bloodwork, etc. etc. and
was pronounced fit as a fiddle. Until a cath was done. I realize
doctors don't routinely perform those, they carry risk and are
extremely expensive too, but IMO it's the only thing that really shows
what's going on in there.
Just my .02.


I was referring specifically both to diagnosing a heart attack
(myocardial infarction) and the differential diagnosis of other cardiac
and noncardiac disorders that can cause similar symptoms. This is in the
critical phase where the patient bas something else than an MI, which
could kill them.

Other than thallium or SPECT nuclear scans with other isotopes, none of
the methods above pretend to localize a blockage. What they do is
identify damage to cardiac muscle, which isn't always due to blockage.
In other words, in the ER, there are things that must be considered
before more detailed examination of blockage.

Much depends on the patient. You can get a strong indication of blockage
and a weak indication of location if the particular patient has certain
ECG changes. My ECG is unremarkable. I'm increasingly of the opinion
that treadmill stress ECG, without ultrasonography or nuclear imaging,
may not be cost-effective and has a high rate of false negatives.

There are several clinical trials that are dealing with early
identification of particular blockages, where it is appropriate to send
an ambulance patient directly to a hospital with angiography and
angioplasty/stenting (new general term being PCI, percutaneous
intervention). This is being balanced, again acute MI, with immediate
injection of thrombolytic agents to break up the blockage just after
it's formed.

Some work suggests that some newer methods of cardiac MRI may be as
accurate as angiography, for a certain range of condition. There's also
some possibility of high-resolution helical CT.
 




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