Clinical rabies - or not?

In the following report, Dr. Mahfoud Brahimi of the Institut Pasteur d'Algérie, shows the value of integrated health care and specialist experience to guide the differential diagnosis of rabies infections in endemic countries:

The Infectious Diseases Service in Algiers (El Kettar Hospital) informed me in June that a nine year old child had been hospitalised, with clinical signs that could be rabies. I took the precaution of taking the necessary kit with me: gloves, eye protectors, transport for samples of saliva and ice for transporting the samples under cold conditions.

When I arrived at the hospital, I met Dr. Abed who showed me the child lying on the bed. He was surrounded by his relatives who never stopped hugging him or speaking to him, despite what the doctors said. He had been in the hospital for seven days, presenting with fever and back pain, and then started to have hallucinations (saying “Bye-bye” to things that only he saw), and periodically, tossing and turning in the bed.

However, the child was doing well and his condition did not look like rabies to me. His face had no signs of fatigue, and he did not remind me at all of rabies cases I had seen previously. There had been no recorded contact with a biting animal and the cats and dogs in the household were all safe and sound, and had been watched closely every day. Some doubt remained, however, as the child used to walk with his friends to a Qur’anic school around 2km from his house. It was possible that he had had contact with an animal, and had hidden it from his parents.

Tests were done and a lymphocyte infection was discovered, which the doctors put down to an unknown viral infection. The child was drinking water normally, and eating, and therefore we agreed that he should not be regarded as having rabies, and instead be treated with analgaesics. I took a first saliva sample easily, but when I tried to take a second one he clenched his jaw, and I was forced to take the second sample between his teeth and the oral mucous membrane. The same day, all the samples were inoculated into newborn mice which had been weened.

I remained in contact with Dr. Abed, who told me the child was improving all the time, and after four days he was discharged. The results of the intracerebral inoculation of the samples were negative, and no mouse had died after 15 days.

It is a miracle that this child had been so well cared for, and a good example of how collaborative working within health teams can benefit everyone involved. It also shows how the care given by the doctors, and the affection shown by the parents saved the life of a child whose case could otherwise have been consigned to the register of human rabies cases for 2013.