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Rabies caused by fox bite is uncommon, most cases being caused by bite of rabid dogs (95%). We report a 45-year-old lady with rabies encephalomyelitis caused by bite of a rabid wild fox (Vulpes vulpes), a species prevalent in the Deccan plateaus of Central India. Though foxes are known to be susceptible to rabies, literature on the pathological changes caused by fox bite rabies in humans is scarce. Unlike the mild histological alterations described in canine rabies, a florid encephalitic process evolved in fox bite rabies, in our case, with intense microglial reaction, neuronophagia and perivascular inflammatory infiltrates despite clinical manifestation as a paralytic rabies. Immunostaining using polyclonal antibodies to the rabies viral nucleocapsid antigen and to the whole virion demonstrated high viral load within neurons with extensive spread along dendritic arborization and axonal tracts. Genomic sequence analysis demonstrated close homology with canine virus strain with only minor variations.

Rabies is an ancient disease of mankind. Every year 4 million people are exposed worldwide after animal bite and around 60000 fell victim to the rabies of which more than 95% of cases are bitten by the dogs. Rabies is a disease associated with many myths. The present study was conducted to find out the clinical profile of the animal bite cases including the common practices, precautions adopted by them after animal bite and lastly the extent and completion of post exposure treatment. Total 147 cases of animal bites attended the OPD during the study. In present study, 123 (83.7%) cases were bitten by dogs, followed by monkey (8.2%) and cat (8.2%). Majority (54.4%) suffered class II bites followed by class I (31.3%) and class III bite (14.3%). Of the total 147 cases, 116 cases (78.9%) completed post exposure prophylaxis which was observed higher among male and in younger age group.

A female nurse, recruited from the Philippines five months previously, developed meningo-encephalitis and was hospitalised. She was later transferred to a hospital in a neighbouring region for specialist treatment. Rabies was part of a differential diagnosis and decisions on public health intervention had to be made in the absence of a firm diagnosis or clinical history. These decisions centred on what infection control measures should be put into effect and when. Issues included the leadership and composition of the incident management team, the coordination of consistent approaches between the health regions and organisations involved, the different priorities of those forming the team and, in particular, contacts with the media and meeting public anxieties.

Objective: To determine the epidemiology of potential rabies exposures in Thai children., Methods: The study was carried out at the Queen Saovabha Memorial Institute of the Thai Red Cross Society during I calendar year. All charts of victims aged 0 to 14 years with possible rabies exposures were retrospectively reviewed., Results: Subjects were 2622 children, with a male to female ratio of 1.6:1 and a mean age of 6.7 years (range, 2 months to 14 years). Most exposures (86.3%) were related to dogs. The most common site of exposure was the lower extremity. The majority of exposures occurred in or around the home and as the consequence of unprovoked attacks rather than provoked attacks. Antirabies vaccines were given in all cases: 68.4% using the Thai Red Cross intradermal route, and 31.6% using the intramuscular route. Rabies immunoglobulin (RIG) was prescribed in 57.5% of children; 35.2% received human RIG (HRIG), and 22.3% received purified equine RIG (ERIG)., Conclusions: This study confirms that rabies exposures, especially in children, are an important public health problem in Thailand. The reduced-dose, multiple-site intradermal rabies vaccine method and ERIG in place of HRIG reduce the cost of treatment.

It is seen that outcome of animal bites is influenced by various factors including the treatment procedures practiced by health care providers (HCPs). A cross sectional study of health care providers was conducted during May 2000 in PHC Kurali and Naraingarh town of community development block Naraingarh in district Ambala, Haryana. A total of forty-four HCPs were interviewed at their health facility. They were asked about the qualification and number of years in practice. Health care providers were assessed for their knowledge regarding history taking, immediate management of animal bite, post bite anti-rabies treatment, follow up advice and availability of vaccines. Pre-exposure prophylaxis was known to 18.8% of HCPs. Fifty-nine per cent of HCPs were confident in managing dog bites and 93.1% knew about tissue culture vaccine. Vaccine cost was the commonest barrier (38.8%) in the management of animal bites. This study shows a gross difference between awareness and actual practice of management of animal bites.

Background: Rabies encephalitis is a feared, virtually uniformly fatal form of central nervous system infection. The incidence of rabies encephalitis in the United States is almost certainly underestimated because of the predominance of bat-borne rabies, which can be spread without traumatic exposure. Because of its rarity in developed countries, rabies encephalitis has been seldom studied with modern imaging techniques., Setting: University-based teaching hospital., Patient: A case of pathologically confirmed rabies encephalitis is presented. Diagnosis of rabies was made by seroconversion testing while the patient was alive and was confirmed postmortem by the presence of rabies antigens and Negri bodies in the brain. The patient had 2 magnetic resonance studies done that showed dramatic abnormalities in the medulla and pons that correlated with features of the neurologic examination and hypothalamic-pituitary abnormalities., Result: The patient had a fulminant encephalitic course that ended in death., Conclusion: Rabies is an uncommon cause of fatal encephalitis. Anatomic imaging studies such as computed tomographic and magnetic resonance scans have generally been negative in confirmed cases of rabies. We report a case of confirmed rabies with extensive brainstem and hypothalamic-pituitary abnormalities on magnetic resonance imaging. Although these findings are nonspecific, they should raise the clinical suspicion of rabies in the setting of aggressive encephalitis of unclear cause, and appropriate diagnostic tests should be performed.

We investigated the role played by inflammation in acute encephalitis following infection with a neurotropic virus by comparing the disease caused by the CVS strain of rabies virus in C57BL/6 and mice deficient for the p55 Kd TNF-alpha receptor (p55TNFR-/-). Morbidity (weight loss and paralysis) and mortality of infected mice were associated with viral propagation, cytokine (IL-6, IL-10, TNF-alpha and IFN-gamma) production, induction of apoptosis and infiltration of inflammatory cells. Mortality occurred later in p55TNFR-/- (than in C57BL/6 mice. In contrast, morbidity and the number of cells undergoing apoptosis were similar in C57BL/6 and p55TNFR-/- mice.) This suggests that morbidity and mortality are independently regulated and that the death of the animal was not due to CNS apoptosis. Delayed mortality correlated with: a reduction in viral load on day 9 p.i., an increase in IFN-gamma and IL-10 concentrations and a reduction in inflammatory cell infiltration in the CNS. Thus, these data indicate that CVS infection elicits an inflammatory response within the CNS and suggest that cytokines signaling via the p55 Kd TNF-alpha receptor is deleterious for the survival of the host. These results strongly suggest that, the modulation of TNF-alpha and upregulation of IFN-gamma would be a powerful anti-virus strategy in cases of viral encephalitis.

A 46-year-old Caucasian man was admitted with a history of dog-bite in a foreign country six months previously. He presented with multisystem complaints, died suddenly soon after admission and the only significant finding at post-mortem was a ruptured oesophagus. Immunological tests confirmed rabies.

Human rabies is a fatal encephalomyelitis. After the development of the central nervous system infection, there is centrifugal spread of the rabies virus to extraneural (systemic) organs. With histochemical staining and localization of rabies virus antigen (RVA) with immunoperoxidase staining, we have examined tissue sections of organs from 14 postmortem pediatric and adult cases of human rabies acquired in Mexico and the People's Republic of China. RVA was found in nerve plexuses in multiple organs, including the gastrointestinal tract. RVA was observed in muscle fibers of the heart, tongue, and larynx. RVA frequently was observed in the adrenal medulla with an associated inflammatory reaction. Minor salivary glands of the tongue contained RVA and major salivary glands showed RVA in plexuses, but not in either acini or ducts. Epithelial cells of the tongue and taste buds were occasionally infected. RVA was observed in hair follicles of the skin and rarely in pancreatic islets. The infection of extraneural organs was sometimes, but not always, associated with an inflammatory reaction. These findings indicate that centrifugal spread of rabies virus to extraneural organs occurs frequently in human rabies.

Cryptosporidial infection was diagnosed histologically in the small intestine of a big brown bat (Eptesicus fuscus) from Oregon. This is the first report of cryptosporidiosis in a bat.

A 49-year-old Moroccan man was admitted to hospital with chest pain and dyspnoea. The next day he had paresis of the left arm and because of respiratory arrest he was transferred to the intensive care unit. A fast-progressive neurological illness developed with flaccid tetraparesis, areflexia and a lowered level of consciousness. He died 11 days after admission. The strong clinical suspicion of rabies was confirmed by very high antibody titres in serum and CSF and by positive immunofluorescence in mice inoculated with the patient's CSF. This was the first case of rabies in the Netherlands since 1963.

Rabies is endemic in India in both wildlife and humans. Human rabies kills 25,000 to 30,000 persons every year. Several types of sexual manifestations including excessive libido may develop in cases of human rabies. A laboratory proven case of rabies in an Indian woman who manifested excessive libido is presented below. She later developed hydrophobia and died.

The treatment of symptomatic rabies is a challenging problem; no specific drug is yet available. Isolation in intensive care unit with symptomatic and supportive measures is the mainstay of treatment at present. Antiviral drugs, particularly interferon and interferon-inducers, have been employed with variable results. Corticosteroid is not effective. Anti-rabies vaccine has no proven efficacy in treatment. Effective treatment of systemic complications during survival period with appropriate therapy is essential.

Three of six wild dogs (Lycaon pictus) which died of rabies, and one Alsatian dog which died of adenocarcinoma, were found to harbour sarcocysts in their cardiac and/or skeletal muscles. The bradyzoites and metrocytes of the cysts were smaller than those seen in a lion infected with Microbesnoitia leoni and the common Sarcocystis spp. found in ruminants. It is proposed that Lycaon pictus is the natural intermediate host of the unidentified Sarcocystis-like species.

A retrospective study of horses necropsied between 1985 and 1989 at a diagnostic laboratory of a veterinary school in North America is documented. In this investigation over 20 per cent of the horses had clinical neurological signs. Equine protozoal myeloencephalitis (caused by Sarcocystis neurona) and cervical stenotic myelopathy (wobbler syndrome) were the most common of these disorders. The veterinary school is located in the midst of a raccoon rabies enzootic area. However, only four cases of equine rabies were diagnosed during the 5-year study. The gross microscopical and immunohistochemical findings from these rabies-positive horses are documented. Immunoperoxidase tests for detection of rabies antigen in another 35 horses with non-specific encephalitis/encephalopathy did not reveal any positive cases. Based on this investigation, it appears that immunoperoxidase is a valid method for diagnosis of rabies when fresh tissues are not available for the fluorescent antibody test. It is also concluded that no cases of equine rabies were overlooked by the diagnostic laboratory during the period under investigation.

Reviewed are the results of 15 years' experience with rabies at You-An Infectious Disease Hospital, Beijing, China. The purpose of the study was to determine whether there are any epidemiological or clinical features of rabies that are unique to China and which might be important in developing a strategy to control it. During the period under study, 64 patients with rabies were admitted to You-An Hospital. Exposure to dogs was associated with 61 cases, two involving the handling of dog carcasses that were being prepared for meals. All of the exposures occurred in rural areas, and none of the patients received adequate prophylaxis. Patients with proximal sites of exposure and with severe injuries developed rabies after short incubation periods (P less than 0.05, and P less than 0.02, respectively). Failed vaccination was also associated with a short incubation period (P less than 0.05). Haematemesis occurred in 20 patients and was associated with shorter incubation periods (P less than 0.02), facial exposure sites (P = 0.021), and severe injuries (P = 0.047). A strategy to control rabies in China should include efforts to educate the public about handling the carcasses of stray dogs, in addition to the currently recommended strategy of controlling the dog population and of vaccinating domesticated animals.

Certain diseases do not consistently affect a single area of the nervous system and, in fact, may cause concomitant multifocal involvement. Depending on the area of the nervous system affected, these diseases may cause a wide spectrum of neurologic problems and therefore must be included in the differential diagnosis for most problems discussed previously. Diseases causing multifocal lesions should especially be suspected when there are concomitant neurologic deficits that cannot be localized to a single site. An example would be a cat with seizures and paraparesis without thoracic limb involvement, in which case separate lesions affecting the forebrain and thoracolumbar spinal cord would be suspected. Inflammatory neurologic diseases most commonly cause lesions at multiple sites and will be discussed here. These conditions frequently cause concomitant systemic disease. Additional disease categories that may cause multifocal lesions, and are somewhat more likely to result in strict neurologic disease, are discussed in Multiple Neurologic Deficits: Non-infectious Diseases (page 440).

Concurrent infection of a raccoon by rabies and canine distemper viruses is described. Fluorescent antibody (FA) test demonstrated rabies antigen in the brain of this animal, however, histologically only lesions characteristic of canine distemper infection were seen. We recommend testing tissues for rabies of animals that histologically are positive for canine distemper.

A patient who returned from India with a gastrointestinal disturbance subsequently developed the clinical features of rabies. The diagnosis was confirmed by isolation of rabies virus from saliva and the demonstration of rising titres of rabies antibody. He was treated in an intensive care unit, ventilated mechanically, and given rabies antiserum, but cerebral activity ceased and he died after 22 days. His course was marked by numerous bouts of cardiac arrhythmia including complete heart block. This case indicates the need for vaccination against rabies to be carried out immediately after exposure to a possibly rabid dog since encephalitis develops a fatal outcome may not be prevented even with intensive medical treatment.

Rabies was diagnosed in 2 adult Quarter Horses with hindlimb hyperesthesia and progressive weakness. Microscopic examination of the cord and brain of the first horse revealed nonsuppurative meningomyelitis and ganglioneuritis in the cord extending cranially to the 6th cervical segment. Fluorescent antibody test results of both horses were positive for rabies in hindlimb peripheral nerve specimens, but negative in sections of the upper lip. Salivary gland, cerebrum, cerebellum, hippocampus, musculocutaneous nerve, cornea, and optic nerve specimens were tested for rabies by fluorescent antibody technique to determine viral distribution in the body of the second horse.

Mice lethally infected with street rabies virus failed to develop cytotoxic T cells specific for rabies virus-infected target cells, whereas high levels of cell-mediated cytotoxicity (CMC) were generated after nonfatal infection with the attenuated high egg passage (HEP) or ERA rabies virus strains. Furthermore concurrent infection with street, but not with HEP, rabies virus suppresses development of a primary (but not a secondary) CMC response specific for influenza virus. No cross-reactivity is found between effector T-cell populations from mice immunized with HEP or with influenza virus. It thus appears that street rabies virus, which is not known to replicate in the cells of immune system, induces some general defect in the primary CMC lymphocyte response, though restimulation of memory T-cell populations is unimpaired and there is no defect in antibody formation. Development of fatal rabies may reflect the operation of this selective immunosuppressive mechanism.

Mice were inoculated intracerebrally or in the footpad with 11 salivary gland suspensions from rabid foxes, skunks, and bobcats. The 11 isolates differed in their ratios of intracerebral titer to footpad titer, a result indicating that the "invasiveness" of different isolates varies markedly. The degree of invasiveness could not be correlated with the species of animal. The inoculation of the less invasive isolates resulted in an appreciable number of permanently paralyzed animals (survivors with sequelae). These animals had high titers of neutralizing antibody in serum but no neutralizing antibody in the brain, a finding suggesting that virus had invaded only the peripheral nervous system or the spinal ganglia. Pathological examination of the paralyzed mice and normal mice confirmed this finding.

The clinical and histopathological manifestations of the infection of immunosuppressed (cyclophosphamide-treated) and immunocompetent (control) adult mice with the CVS ts 2 strain of fixed rabies virus were correlated with the kinetics of virus multiplication in the central nervous system and with the development of serum antibody. In immunocompetent mice severe paralytic disease causing 80% mortality was accompanied by marked inflammation and degeneration of the central nervous system parenchymatous tissue. Antirabies antibody was detected in all immunocompetent mice severely paralyzed from postinoculation day 6 on; virus was rarely isolated. In contrast, immunosuppressed mice developed encephalitic symptoms with only minor paralysis; the infection was 100% fatal. Histopathological changes in immunosuppressed mice were confined to degeneration and necrosis of individual neurons and mild microglial reaction; virus was isolated from all of these mice. No significant level of antibody was detected. Similar manifestations were seen after infection of immunodeficient (athymic) mice except that the athymic mice developed levels of antibody similar to those of control mice on day 6; antibodies in athymic mice were predominantly of immunoglobulin class M.

Psychiatrists in South Africa do not expect to encounter rabies in the course of clinical practice. Two cases of this fatal disease presenting as acute psychiatric emergencies, mistakenly suspected at first of being schizophrenia and delirium tremens, are briefly described. Reasons for initial doubt and delay in diagnosis are mentioned and concern mainly uncertainty about the incubation period or changes in the spinal fluid.

Rabies is a rare, fatal viral infection, usually transmitted by the bite of an infected animal. Some 30,000 Americans are immunized annually, however, so public health considerations are common. The development of a new vaccine, grown in human diploid cell culture, is discussed. It appears to have high antigenicity with no serious morbidity. A case of a patient with fatal rabies who had fever, delirium, dysphagia, and cervical and pectoral subcutaneous emphysema is presented.

A case of rabies was treated with intensive medical support. This led to a prolongation of life to 25 days. The neurologic progression of the disease was monitored clinically and with serial EEG. This prolonged course enabled us to witness and manage a wide variety of unusual complications including the adult respiratory distress syndrome, hypothermia, myocarditis, and diabetes insipidus. This report documents the clinical features, diagnostic problems, complications, and management.