Rabies is a notifiable disease in many countries.
Preventable through prompt medical care. Post-exposure prophylaxis with wound cleansing, immunisation, and rabies immunoglobulin is highly effective at preventing the disease when given promptly and properly.
Symptoms begin with a non-specific prodromal illness. In encephalitic rabies, this is followed by early-onset behavioural changes and late-onset paralysis. In the paralytic form, the behavioural changes are absent.
Almost always fatal following onset of clinical signs. The disease is rapidly progressive, leading to death within 2 weeks in most cases. Some survivors have been reported.
Pre-exposure prophylaxis is recommended for certain people at high risk for exposure.
An acute viral encephalomyelitis caused by the rabies virus and other members of the Lyssavirus genus, which is transmitted by animal bites, mainly dogs in developing countries and bats in other countries including the US.
The World Health Organization (WHO) has set a global goal to achieve no human deaths from dog-transmitted rabies by 2030.
History and exam
Key diagnostic factors
- presence of risk factors
- limb numbness, pain, and paraesthesia
- change in behaviour
- agitation and confusion
- signs of autonomic instability
- rapid progression of symptoms
- weakness and paralysis
Other diagnostic factors
- urinary or faecal incontinence
- abdominal pain
- slurred or stuttered speech
- recent scratch or bite from a known vector
- travel to/living in rabies-endemic country
- occupational or recreational exposure
- age <15 years
1st investigations to order
- saliva PCR and viral culture
- skin biopsy (neck) with direct fluorescent antibody (DFA) and PCR
- CSF cytology
- CSF biochemistry
- CSF rabies neutralising antibody
- serum rabies IgM or IgG
- CSF herpes simplex PCR
- CSF enterovirus PCR
- CSF West Nile virus IgM
- serum N-methyl-D-aspartate (NMDA) glutamate receptor antibodies
Investigations to consider
- serum arbovirus antibodies
- serum Bartonella antibodies
- serum Rickettsia antibodies
- head MRI
asymptomatic with recent vector exposure
Sergio Recuenco, MD, MPH, DrPH
Faculty of Medicine Sa Fernando
National University of San Marcos
SR declares that he has no competing interests.
Rodney Willoughby, MD
Medical College of Wisconsin
RW is an author of a number references cited in this topic.
Dr Sergio Recuenco and Dr Rodney Willoughby would like to gratefully acknowledge Dr Kis Robertson, a previous contributor to this topic.
KR declares that she has no competing interests.
Peter Leggat, MD
School of Public Health
Tropical Medicine and Rehabilitation Sciences
Faculty of Medicine
Health and Molecular Sciences
James Cook University
PL is a member of the Australian Travel Health Advisory Group that is supported by a grant from GlaxoSmithKline. PL has received travel grants from GlaxoSmithKline to attend travel medical conferences in the last 5 years.
Allan Grill, MD, CCFP, MPH
Department of Family and Community Medicine
Dalla Lana School of Public Health
University of Toronto
AG declares that he has no competing interests.
- Herpes simplex virus infection
- Enterovirus meningoencephalitis
- West Nile virus encephalitis
- Use of a modified preexposure prophylaxis vaccination schedule to prevent human rabies
- Guidelines on managing rabies post-exposure
- Log in or subscribe to access all of BMJ Best Practice
Use of this content is subject to our disclaimer