Rabid Bat Rabies Warning (cont.)

In September 2003, the patient was admitted to a hospital emergency department (ED) for assessment of atypical chest pain. He had a 2-week history of mild, nonspecific complaints (e.g., drowsiness, chronic headache, and malaise), a 5-day history of progressive right arm pain and paresthesias, and a 1-day history of right-hand weakness. The arm pain was severe enough to wake him from sleep and progressively worsened. He also described a sharp pain radiating bilaterally up the right arm to his axilla and left chest. The pain was relieved by administering nitroglycerin in the ED. The patient reported being bitten by a bat on the right index finger while in his bed approximately 5 weeks before admission. He removed the bat from his home, and it flew away. The patient washed the wound but did not seek rabies postexposure prophylaxis (PEP) at that time. Because the patient reported to the ED at an early stage of rabies infection, with predominantly local symptoms near the bite site, rabies vaccine, rabies immune globulin, ribavirin, and interferon-alpha were administered on the day of admission; a second dose of rabies vaccine was administered 3 days later.

On admission, he was afebrile, alert, and oriented but had decreased right upper extremity strength, decreased sensation to light touch, and slight impairment in his ability to concentrate. His white blood cell (WBC) count was elevated at 13,900 cells/L (normal: 3,700--9,400 cells/L). All other laboratory values were within the normal range.

The patient had steady neurologic decline during the following week with confusion and disorientation. He became febrile on the fourth hospital day and was intubated for airway protection. Electromyography of his right and left upper extremities indicated distal demyelinating polyneuropathy. By the fifth hospital day, he had a right lung infiltrate, and his electroencephalogram showed diffuse slowing. Two days later, he died. Four family members and two of 40 health-care workers involved in the patient's treatment received rabies PEP as a precautionary measure. The patient's wife received PEP because she had been asleep in the same bed as the patient when the bat bit him and possibly had been exposed to the same bat.

Antemortem specimens were sent to the Viral and Rickettsial Disease Laboratory (VRDL) at CDHS and to CDC for evaluation. The specimens included multiple saliva and serum samples, nuchal skin biopsy, urine, and spinal fluid. Postmortem corneal impressions also were obtained. A nested, reverse transcription polymerase chain reaction assay performed on saliva samples was positive for evidence of rabies virus nucleic acid. Sequence analysis demonstrated 100% homology with a rabies virus variant associated with the silver-haired bat (Lasionycteris noctivagans).