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Volume 13, Number 1—January 2007

Dispatch

Rabies Encephalitis in Malaria-Endemic Area, Malawi, Africa

Macpherson Mallewa*†, Anthony R. Fooks‡, Daniel Banda†, Patrick Chikungwa§, Limangeni Mankhambo†, Elizabeth Molyneux†, Malcolm E. Molyneux†, and Tom Solomon*Comments to Author 
Author affiliations: *University of Liverpool, Liverpool, United Kingdom; †College of Medicine, Blantyre, Malawi; ‡Veterinary Laboratories Agency (Weybridge) WHO Collaborating Centre for the Characterisation of Rabies and Rabies-Related Viruses, Surrey, United Kingdom; §Central Veterinary Laboratory, Lilongwe, Malawi;

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Table

Clinical and diagnostic features of 14 patients for whom the ultimate diagnosis was rabies encephalitis*

Patient no (sex/age,y)Clinical featuresHistory of animal exposureAdmission coma score†Malaria slide‡Clinical diagnosisTime to deathPostmortem positive results
1 (F/13)Fever and confusion for 2 d; convulsions, hypersalivation, hydrophobia, aerophobiaUncertain13/15NegRabies24 hND
2 (M/13)Hallucinations, confusion, for 2 d; thought had "been bewitched"; pyrexia, neck stiffness, drooling hydrophobia, aerophobiaPossible dog bite 6 mo earlier12/15NegRabies12 hND
3 (M/6)Fever for 2 d, convulsions for 1 d; agitated, hydrophobia, aerophobiaDog bite 3 mo earlier3/5Pos (1+)Rabies4 dND
4 (M/7)Fever for 2 d, confusion, drooling, hydrophobia, aerophobiaDog bite 3 mo earlier4/5NegRabies24 hND
5 (M/8)
Fever for 2 d, convulsions; confused; rapid deterioration
None§
4/5
Pos (2+)
Cerebral malaria
3 d
FAT, PCR, MIT
6 (M/7)Headache, fever for 3 d, weak, confused; mild neck stiffness, reduced tone, reflexes; CSF 8 leukocytes /mm3, protein 40 mg/dL, glucose 4.8 mmol/L; venous glucose 5.5 mmol/L; deteriorated over 10 dCat scratch 3 mo earlier2/5Pos (1+)Cerebral malaria10 dFAT,¶ PCR, MIT
7 (M/6)Fever for 1 d, convulsions; neck stiffness, hydrophobia, aerophobiaDog bite 2 mo earlier3/5Pos (2+)Rabies<6 hND
8 (M/13)Restlessness, hypersalivation, hematemesis for 1 d; confused, hydrophobia, aerophobiaDog bite 3 mo earlier13/15NegRabies<6 hND
9 (F/11)Fever, restlessness for 1 d; agitated, hydrophobia, aerophobiaDog bite, 1 mo earlier14/15NegRabies4 dFAT, PCR, MIT
10 (M/7)
Fever confusion for 1 d, hallucination, “bewitched”, hypersalivation, confusion, hydrophobia, aerophobia
Dog bite 2 mo earlier
1/5
Neg
Rabies
24 h
FAT, PCR, RTCIT
11 (F/6)Fever convulsions for 1 d; status epilepticus, hypotonia, areflexia developed; diffuse slow waves on EEGNone§1/5Pos (2+)Cerebral malaria<6 hPCR
12 (M/12)Fell off bike, head injury, no loss of consciousness; ataxia and confusion developed; neck stiffness, fever; CSF 65 leukocytes/mm3 (70% PMN cells) protein 30 mg/dL, glucose 4.2 mmol/LNone§14/15NegMeningitis3 dFAT, PCR, MIT
13 (M/7)Fever for 2 d, convulsion, reduced conscious; agitated, convulsions, hydrophobia, aerophobiaDog bite 6 wk earlier2/5NegRabies24 hND
14 (M/6)Fever for 2 d, vomiting 1 d, no convulsions; confused, hydrophobia, aerophobiaDog bite 2 mo earlier4/5NegRabies24 hND

*Neg, negative; Pos, positive; ND, not done; FAT, fluorescent antibody test; PCR, reverse transcriptase–PCR; MIT, mouse inoculation test; CSF, cerebrospinal fluid; RTCIT, rabies tissue culture inoculation test; EEG, electroencephalogram; PMN, polymorphonuclear.
†Glasgow coma score /15 or Blantyre coma score /5.
Plasmodium falciparum parasitemia, graded according to the number of parasitized red blood cells per high-powered field (HPF) 1+= 1–100/100 HPF, 2+ = 1–9/10 HPF, 3+ = 1–9 per field, 4+ = >10/HPF) (11).
§For patients 5, 11, and 12, a possible exposure history was elicited after the diagnosis of rabies encephalitis became apparent. Patient 5 had been scratched by a dog 6 wks earlier, but it had not appeared rabid; patient 11 had been bitten by a neighbor’s dog 6 mo before admission, although this animal had been vaccinated against rabies, and remained well; patient 12 had been bitten by a neighbor’s dog 4 mo earlier, the dog remained well, although another dog had died after apparently “choking on a rat” (rabid dogs often appear to have something stuck in their throat).
¶Patient 6 CSF was negative for rabies virus by FAT at the Veterinary Laboratories Agency Weybridge but positive when tested in Malawi.

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