eMedicine Specialties > Pediatrics: General Medicine > Infectious Disease

Rabies: Differential Diagnoses & Workup

Author: Donna J Fisher, MD, Assistant Professor, Department of Pediatrics, Division of Pediatric Infectious Diseases, Tufts University School of Medicine and Baystate Children's Hospital, Baystate Medical Center
Contributor Information and Disclosures

Updated: Oct 9, 2008

Differential Diagnoses

Other Problems to Be Considered

Other encephalitides (especially herpes simplex encephalitis because it is treatable)
Guillain-Barré syndrome, transverse myelitis, and poliomyelitis (Patients may present with similar paralytic features.)
Tetanus (Rigidity of tetanus contractions is more prolonged, with mental status usually normal.)
Epilepsy
Poisoning with atropinelike compounds
Pseudohydrophobia (hysterical reaction to animal bites)

Workup

Other Tests

Diagnostic studies for rabies include the following:

  • Brain biopsy with immunohistochemical or florescent antibody staining is definitive. Euthanize wild animals that have been captured after biting and have state health departments test the unfixed brain tissue.12
  • In suspected human cases, perform skin biopsy from the nape of the neck or, less preferably, obtain a smear of corneal epithelial cells for similar specific stains.
  • Rise in specific neutralizing antibodies on rapid fluorescent focus inhibition testing (RFFIT) is often not documented in true rabies cases because the victims succumb to the disease prior to mounting a response. Serologic testing is more useful to ascertain serostatus in immunized animals and humans.20
  • Viral culture of saliva, cerebrospinal fluid, and brain can also be performed in specialized laboratories. These tissue specimens can also be tested using polymerase chain reaction (PCR).

Procedures

  • Wound debridement at the time of patient evaluation is essential, along with careful cleaning of the wound for longer than 10 minutes.
  • Generally, leave wounds to heal by secondary intention.21,20

Histologic Findings

  • General findings on pathology include cerebral congestion and inflammation typical of encephalitis.
  • Immunohistochemical or fluorescent antibody staining of nervous tissue, usually of unfixed brain or skin biopsy specimens with sensory nerve endings, reveals deposition of virion in the cytoplasm.
  • Negri bodies are observed in neurons on light microscopy and represent round cytoplasmic inclusions of assembling nucleocapsid. Only 70% of brain biopsy tissue exhibits this finding in human rabies encephalitis.
  • Electron microscopy is more sensitive than light microscopy and reveals the characteristic bullet-shaped virion.

More on Rabies

Overview: Rabies
Differential Diagnoses & Workup: Rabies
Treatment & Medication: Rabies
Follow-up: Rabies
Multimedia: Rabies
References
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References

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  2. Srinivasan A, Burton EC, Kuehnert MJ, et al. Transmission of rabies virus from an organ donor to four transplant recipients. N Engl J Med. Mar 17 2005;352(11):1103-11. [Medline]. [Full Text].

  3. Centers for Disease Control and Prevention. Investigation of rabies infections in organ donor and transplant recipients--Alabama, Arkansas, Oklahoma, and Texas, 2004. MMWR Morb Mortal Wkly Rep. Jul 9 2004;53(26):586-9. [Medline].

  4. Centers for Disease Control and Prevention. Human death associated with bat rabies--California, 2003. MMWR Morb Mortal Wkly Rep. Jan 23 2004;53(2):33-5. [Medline].

  5. Pape WJ, Fitzsimmons TD, Hoffman RE. Risk for rabies transmission from encounters with bats, Colorado, 1977- 1996. Emerg Infect Dis. May-Jun 1999;5(3):433-7. [Medline].

  6. Blanton J D, Hanlon CA, Rupprecht CE. Rabies surveillance in the United States during 2006. J Am Vet Med Assoc. Aug 15 2007;231(4):540-56. [Medline].

  7. Wyatt JD, Barker WH, Bennett NM, Hanlon CA. Human rabies postexposure prophylaxis during a raccoon rabies epizootic in New York, 1993 and 1994. Emerg Infect Dis. May-Jun 1999;5(3):415-23. [Medline].

  8. Centers for Disease Control and Prevention (CDC). First human death associated with raccoon rabies--Virginia, 2003. MMWR Morb Mortal Wkly Rep. Nov 14 2003;52(45):1102-3. [Medline].

  9. Compendium of animal rabies prevention and control, 2008: National Association of State Public Health Veterinarians, Inc. (NASPHV). MMWR Recomm Rep. Apr 18 2008;57:1-9. [Medline]. [Full Text].

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  11. Nel LH, Markotter W. Lyssaviruses. Crit Rev Microbiol. 2007;33(4):301-24. [Medline].

  12. Baer GM. The Natural History of Rabies. Boston, MA: CRC Press; 1991.

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  18. Willoughby RE, Tieves KS, Hoffman GM, et al. Survival after treatment of rabies with induction of coma. N Engl J Med. Jun 16 2005;352(24):2508-14. [Medline]. [Full Text].

  19. McDermid RC, Saxinger L, Lee B, et al. Human rabies encephalitis following bat exposure: failure of therapeutic coma. CMAJ. Feb 26 2008;178(5):557-61. [Medline].

  20. Manning SE, Rupprecht CE, Fishbein D, et al. Human rabies prevention--United States, 2008: recommendations of the Advisory Committee on Immunization Practices. MMWR Recomm Rep. May 23 2008;57:1-28. [Medline]. [Full Text].

  21. Goldstein EJ. Current concepts on animal bites: bacteriology and therapy. Curr Clin Top Infect Dis. 1999;19:99-111. [Medline].

  22. Moran GJ, Talan DA, Mower W, et al. Appropriateness of rabies postexposure prophylaxis treatment for animal exposures. Emergency ID Net Study Group. JAMA. Aug 23-30 2000;284(8):1001-7. [Medline].

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  28. Chutivongse S, Wilde H, Benjavongkulchai M, et al. Postexposure rabies vaccination during pregnancy: effect on 202 women and their infants. Clin Infect Dis. Apr 1995;20(4):818-20. [Medline].

  29. Arya SC, Agarwal N. Assessing the safety of post-exposure rabies immunization in pregnancy. Hum Vaccin. Sep-Oct 2007;3(5):155; author reply 155. [Medline].

  30. Abazeed ME, Cinti, S. Rabies prophylaxis for pregnant women. Emerg Infect Dis. Dec 2007;13(12):1966-7. [Medline].

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Further Reading

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Keywords

rabies, terrestrial rabies, hydrophobia, mad dog disease, bat rabies, avian rabies, paralytic rabies, dumb rabies, furious rabies, rabies virus, rhabdovirus, Lyssavirus, Rhabdoviridae, encephalitis, raccoon bite, bat bite, paralysis, altered mental status, anxiety, hyperactivity, hypertension, hypersalivation, hyperthermia, hyperventilation

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Contributor Information and Disclosures

Author

Donna J Fisher, MD, Assistant Professor, Department of Pediatrics, Division of Pediatric Infectious Diseases, Tufts University School of Medicine and Baystate Children's Hospital, Baystate Medical Center
Donna J Fisher, MD is a member of the following medical societies: American Academy of Pediatrics, American Society for Microbiology, Infectious Diseases Society of America, and Pediatric Infectious Diseases Society
Disclosure: Nothing to disclose.

Medical Editor

Rosemary Johann-Liang, MD, Medical Officer, Infectious Diseases and Pediatrics, Division of Special Pathogens and Immunological Drug Products, Center for Drug Evaluation and Research, Food and Drug Administration
Rosemary Johann-Liang, MD is a member of the following medical societies: American Academy of Pediatrics, American Medical Association, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from broker recommendation; Avanir Pharma Stock Investment from broker recommendation

Managing Editor

Leslie L Barton, MD, Professor, Program Director, Department of Pediatrics, University of Arizona School of Medicine
Leslie L Barton, MD is a member of the following medical societies: American Academy of Pediatrics, Association of Pediatric Program Directors, Infectious Diseases Society of America, and Pediatric Infectious Diseases Society
Disclosure: Nothing to disclose.

CME Editor

Robert W Tolan Jr, MD, Chief, Division of Allergy, Immunology and Infectious Diseases, The Children's Hospital at Saint Peter's University Hospital; Clinical Associate Professor of Pediatrics, Drexel University College of Medicine
Robert W Tolan Jr, MD is a member of the following medical societies: American Academy of Pediatrics, American Medical Association, American Society for Microbiology, American Society of Tropical Medicine and Hygiene, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, Phi Beta Kappa, and Physicians for Social Responsibility
Disclosure: GlaxoSmithKline Honoraria Speaking and teaching; MedImmune Honoraria Consulting; MedImmune Honoraria Speaking and teaching; Merck Honoraria Speaking and teaching; Novartis Honoraria Speaking and teaching; sanofi pasteur Grant/research funds Unrestricted research grant; sanofi pasteur  Consulting; sanofi pasteur Honoraria Speaking and teaching; Tap Honoraria Speaking and teaching

Chief Editor

Russell W Steele, MD, Head, Division of Pediatric Infectious Diseases, Ochsner Children's Health Center; Clinical Professor, Department of Pediatrics, Tulane University School of Medicine
Russell W Steele, MD is a member of the following medical societies: American Academy of Pediatrics, American Association of Immunologists, American Pediatric Society, American Society for Microbiology, Infectious Diseases Society of America, Louisiana State Medical Society, Pediatric Infectious Diseases Society, Society for Pediatric Research, and Southern Medical Association
Disclosure: None None None

 
 
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