Summary
Definition
History and exam
Key diagnostic factors
- history of recent scratch or bite from known vector
- hydrophobia
- aerophobia
- limb numbness, pain, and paresthesia
- pruritus
- dysphagia
- fever
- change in behavior
- agitation and confusion
- hallucination
- signs of autonomic instability
- rapid progression of symptoms
- weakness and paralysis
Other diagnostic factors
- urinary or fecal incontinence
- coma
- abdominal pain
- insomnia
- seizures
- slurred or stuttered speech
- ataxia
Risk factors
- recent scratch or bite from known vector
- travel to/living in rabies-endemic country
- occupational or recreational exposure
- age <15 years
Diagnostic tests
1st tests to order
- saliva PCR and viral culture
- skin biopsy (neck) with direct fluorescent antibody (DFA) and PCR
- CSF cytology
- CSF biochemistry
- CSF rabies neutralizing 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
Tests to consider
- serum arbovirus antibodies
- serum Bartonella antibodies
- serum Rickettsia antibodies
- head MRI
Treatment algorithm
asymptomatic with recent vector exposure
symptomatic rabies
Contributors
Authors
Sergio Recuenco, MD, MPH, DrPH
Associate Professor
Faculty of Medicine Sa Fernando
National University of San Marcos
Lima
Peru
Disclosures
SR declares that he has no competing interests.
Rodney Willoughby, MD
Professor
Pediatrics
Medical College of Wisconsin
Milwaukee
WI
Disclosures
RW is an author of a number of references cited in this topic.
Acknowledgements
Dr Sergio Recuenco and Dr Rodney Willoughby would like to gratefully acknowledge Dr Kis Robertson, a previous contributor to this topic.
Disclosures
KR declares that she has no competing interests.
Peer reviewers
Peter Leggat, MD
Head
School of Public Health
Tropical Medicine and Rehabilitation Sciences
Faculty of Medicine
Health and Molecular Sciences
James Cook University
Townsville
Queensland
Australia
Disclosures
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
Assistant Professor
Department of Family and Community Medicine
Dalla Lana School of Public Health
University of Toronto
Toronto
Ontario
Canada
Disclosures
AG declares that he has no competing interests.
References
Key articles
World Health Organization. Weekly epidemiological record. Rabies vaccines: WHO position paper. April 2018 [internet publication].Full text
Centers for Disease Control and Prevention. Use of a modified preexposure prophylaxis vaccination schedule to prevent human rabies: recommendations of the Advisory Committee on Immunization Practices - United States, 2022. May 2022 [internet publication].Full text
World Health Organization. WHO expert consultation on rabies: WHO TRS N°1012 (third report). April 2018 [internet publication].Full text
Rupprecht CE, Briggs D, Brown CM, et al; Centers for Disease Control and Prevention. Use of a reduced (4-dose) vaccine schedule for postexposure prophylaxis to prevent human rabies: recommendations of the Advisory Committee on Immunization Practices. MMWR Recomm Rep. 2010;59:1-9.Full text Abstract
Willoughby RE Jr, Tieves KS, Hoffman GM, et al. Survival after treatment of rabies with induction of coma. N Engl J Med. 2005;352:2508-2514.Full text Abstract
Reference articles
A full list of sources referenced in this topic is available to users with access to all of BMJ Best Practice.
Differentials
- Herpes simplex virus infection
- Enterovirus meningoencephalitis
- West Nile virus encephalitis
More DifferentialsGuidelines
- CDC Yellow Book: health information for international travel - rabies
- Use of a modified preexposure prophylaxis vaccination schedule to prevent human rabies
More Guidelines
Log in or subscribe to access all of BMJ Best Practice
Use of this content is subject to our disclaimer