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Imported Human Rabies -- Australia, 1987
In November 1987, the illness of a 10-year-old Australian boy
who
had died of acute encephalitis 4 months earlier was confirmed as
being
rabies. This is the first laboratory-confirmed case of human or
animal
rabies ever reported from Australia.
The child had traveled with his mother to India, Pakistan,
Nepal,
Singapore, and Thailand between February and October of 1986, but
no
animal bites were reported during this period. He remained well
until
June 23, 1987, when headache developed, followed by fever,
vomiting,
and chills. During the next few days, he became anorexic, had a
few
episodes of delirium at night, and had pain in his right arm.
Eight
days after the onset of illness, incoordination and diplopia
developed, along with a progressive weakness in his legs. When
admitted to a local hospital, the patient had palsies of the sixth
cranial nerve on the right side and of the seventh cranial nerve
bilaterally. Analysis of a cerebrospinal fluid specimen showed
normal
cell counts and normal protein and glucose levels. A diagnosis of
atypical Guillain-Barr*$$*Aae syndrome versus encephalitis was
made,
and on the 10th day of illness the patient was transferred to a
regional medical center. At that time, he was unable to walk, and
his
reflexes were decreased on the right side. An electroencephalogram
showed slow wave activity consistent with a diffuse encephalitis,
and
a computerized axial tomography scan was normal. A repeated lumbar
puncture on the 12th day of illness showed 50 white blood
cells/mm3,
18 red blood cells/mm3, elevated glucose, and normal protein
levels.
The patient was temporarily intubated because of irregular
respiration. On the 14th day of illness, inappropriate
antidiuretic
hormone secretion, upper airway obstruction, and pneumonia
developed,
and the left lung collapsed. Seizures began 2 days later. The
patient
became comatose on the 19th day of illness, and he died 4 days
later.
Hospital pathologists found eosinophilic intracytoplasmic
inclusions, suggestive of Negri bodies, on fixed sections of brain
tissue. A serum sample taken on the 21st day of illness had a
rabies
neutralizing antibody titer of 1,400 when analyzed at a reference
laboratory 4 months later. No specimens were available for virus
isolation.
In December, extensive interviews with relatives, friends, and
other contacts of the patient revealed that the patient, an animal
lover, had been injured by two animals in the 2 years before his
death. He was severely scratched by a neighbor's dog 2 months
before
his onset of illness, but the dog remained healthy and did not
have
rabies antibodies when tested in December 1987. However, according
to
a travel companion, the patient was bitten on a finger by a wild
monkey at a marketplace in northern India 16 months before the
onset
of illness. This incident was not reported to the boy's mother. A
photograph of the patient feeding the monkeys at this marketplace
was
found in a school project he had prepared.
Rabies postexposure prophylaxis was recommended for nine
health-care workers and four family members and friends who may
have
been exposed to the patient's saliva or nerve tissue during his
illness.
Reported by: K Dunn, BVSc, Commonwealth Dept of Primary Industries
and
Energy, Barton, Australian Capital Territory. J Faoagali, MBCHB, H
Samartunga, MB, Royal Brisbane Hospital, Brisbane; P DeBuse, MB, D
Fraser, MB, Royal Children's Hospital, Brisbane; R Stable, MBBS, B
Patten, FRACP, D Martin, MBBS, Nambour General Hospital, Nambour;
LL
Laws, MVSc, Queensland Dept of Primary Industries, Moorooka; T St.
George, PhD, Div of Tropical Animal Production, Commonwealth
Scientific and Industrial Research Organization, Indooroopilly; RA
Ramm, MB, RP Davison, MB, V Kelk, Queensland Dept of Health.
Australian Animal Health Laboratory, Commonwealth Scientific and
Industrial Research Organization, Geelong, Victoria. Australian
Dept
of Community Svcs and Health. Viral and Rickettsial Zoonoses Br,
Div
of Viral Diseases, Center for Infectious Diseases, CDC.
Editorial Note: All available data indicate that this was an
imported case of rabies. The only previous report of animal or
human
rabies in Australia is poorly documented, but, in 1867, a child
and a
dog from Tasmania had suspected rabies (1). Both animal and human
rabies have been reported from all the countries in which the
patient
traveled except Singapore (2). (Nepal did not contribute to that
survey.) The monkey bite in northern India 16 months before the
onset
of illness must be considered the probable exposure, but the
patient
might have received other unreported bites while traveling in
Asia. If
the patient was exposed in Asia, the incubation period would have
been
between 8 and 16 months. In one large study of human rabies,
approximately 1% of cases had incubation periods of over 1 year
(3).
Cases of monkey-transmitted human rabies are rare; however, one
extremely long incubation period (37.5 months) was reported (4).
In the Australian boy's case, paralysis dominated the clinical
picture. The clinical picture and the prolonged course before the
onset of coma are consistent with the paralytic form of rabies,
which
occurs in approximately 20% of cases (3).
Since Australia is considered a rabies-free country (2),
animal
rabies vaccination is not required and animals that bite people
are
not quarantined. If animal rabies should become endemic in
Australia,
an estimated 38,000 people per year might have to receive
postexposure
prophylaxis (5). In addition, millions of dollars would have to be
spent on animal rabies vaccination and quarantine. Wild animals
that
might become reservoirs if rabies should be introduced into
Australia
include the dingo (a wild dog), red fox, feral cat, and bat. A
limited
serosurvey of bats in Queensland for rabies antibodies is in
progress.
This report emphasizes the importance of rabies preexposure
prophylaxis for travelers visiting rabies-endemic countries for
more
than 30 days (6), especially children who are likely to have
unrecognized or unreported exposures. Preexposure prophylaxis can
be
administered intramuscularly or intradermally (7); however, the
intradermal regimen should be completed at least 30 days before
departure and should not be used if the person is taking
chloroquine
for malaria chemoprophylaxis.
References
Bisseru B. Rabies. London: William Heinemann Medical Books,
1972:18.
World Health Organization. World survey of rabies XXII (for
years
1984/85). Geneva: World Health Organization, Division of
Communicable Diseases, 1987.
Hattwick MAW. Human rabies. Public Health Rev 1974;3:229-74.
Wilson JM, Hettiarachchi J, Wijesuriya LM. Presenting features
and
diagnosis of rabies. Lancet 1975;2:1139-40.
Nixon J, Pearn J, McGarn F. Dog bite injuries to children:
potential rabies threat to Australia. Med J Aust 1980;1:175-6.
Centers for Disease Control. Health information for
international
travel 1987. Washington, DC: US Department of Health and Human
Services, Public Health Service, 1987:108-12; DHHS publication
no.
(CDC)85-8280.
Immunization Practices Advisory Committee. Rabies prevention:
supplementary statement on the preexposure use of human
diploid
cell rabies vaccine by the intradermal route. MMWR
1986;35:767-8.
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