Human rabies encephalitis following bat exposure: failure of therapeutic coma

We performed a nuchal skin biopsy and obtained saliva and serum samples for rabies virologic and serologic testing. Direct fluorescent antibody staining indicated that the skin biopsy contained rabies virus antigen, and reverse-transcriptase polymerase chain reaction indicated that both the skin and saliva samples contained the rabies virus. Diagnostic tests available for suspected rabies cases in Canada are described in Box 1. The patient received an intramuscular injection of 1200 IU of human rabies immune globulin. For suspected rabies exposures, urgent consultation with a public health official is required. Any bite, wound or exposed surface should be immediately irrigated and washed with soap and water. Wound closure should be avoided. Antibiotics and tetanus prophylaxis should be given as necessary. Clothing that may have been contaminated should be removed. The Canadian Immunization Guide outlines recommendations for postexposure prophylaxis for people who have not been previously vaccinated against rabies. 8 Postexposure prophylaxis should not be delayed if there has been significant exposure to a high-risk wild animal, such as a bat, skunk, fox or raccoon. In cases involving healthy, domesticated animals, such as dogs, cats or ferrets that can be observed for symptoms for 10 days, postexposure prophylaxis may be deferred until signs of rabies develop in the quarantined animal or until the testing on the euthanized animal's brain is negative. If the animal remains healthy for 10 days, postexposure prophylaxis is not required. However, people who are bitten in the head or neck by a domesticated animal should start postexposure prophylaxis immediately and stop treatment if rabies in the animal is ruled out. Five additional cases of human rabies treated with the Milwaukee Protocol have recently been described (Table 1).18-20 None of the patients had received postexposure prophylaxis, they all presented with clinical disease, and none survived. Interestingly, despite the detection among these patients of antibodies specific to the rabies virus, which suggests an immune response, and evidence of viral clearance, autopsies of most of the patients still revealed the presence of the rabies virus. In our patient, there was radiographic deterioration and no evidence of recovery despite treatment with the Milwaukee Protocol. Based on the hypothesis that rabies encephalitis may genuinely mimic clinical brain death and that the only surviving case known appeare