Volume 13, Number 1—January 2007
Rabies Encephalitis in Malaria-Endemic Area, Malawi, Africa
|Patient no (sex/age,y)||Clinical features||History of animal exposure||Admission coma score†||Malaria slide‡||Clinical diagnosis||Time to death||Postmortem positive results|
|1 (F/13)||Fever and confusion for 2 d; convulsions, hypersalivation, hydrophobia, aerophobia||Uncertain||13/15||Neg||Rabies||24 h||ND|
|2 (M/13)||Hallucinations, confusion, for 2 d; thought had "been bewitched"; pyrexia, neck stiffness, drooling hydrophobia, aerophobia||Possible dog bite 6 mo earlier||12/15||Neg||Rabies||12 h||ND|
|3 (M/6)||Fever for 2 d, convulsions for 1 d; agitated, hydrophobia, aerophobia||Dog bite 3 mo earlier||3/5||Pos (1+)||Rabies||4 d||ND|
|4 (M/7)||Fever for 2 d, confusion, drooling, hydrophobia, aerophobia||Dog bite 3 mo earlier||4/5||Neg||Rabies||24 h||ND|
|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 d||Cat scratch 3 mo earlier||2/5||Pos (1+)||Cerebral malaria||10 d||FAT,¶ PCR, MIT|
|7 (M/6)||Fever for 1 d, convulsions; neck stiffness, hydrophobia, aerophobia||Dog bite 2 mo earlier||3/5||Pos (2+)||Rabies||<6 h||ND|
|8 (M/13)||Restlessness, hypersalivation, hematemesis for 1 d; confused, hydrophobia, aerophobia||Dog bite 3 mo earlier||13/15||Neg||Rabies||<6 h||ND|
|9 (F/11)||Fever, restlessness for 1 d; agitated, hydrophobia, aerophobia||Dog bite, 1 mo earlier||14/15||Neg||Rabies||4 d||FAT, 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 EEG||None§||1/5||Pos (2+)||Cerebral malaria||<6 h||PCR|
|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/L||None§||14/15||Neg||Meningitis||3 d||FAT, PCR, MIT|
|13 (M/7)||Fever for 2 d, convulsion, reduced conscious; agitated, convulsions, hydrophobia, aerophobia||Dog bite 6 wk earlier||2/5||Neg||Rabies||24 h||ND|
|14 (M/6)||Fever for 2 d, vomiting 1 d, no convulsions; confused, hydrophobia, aerophobia||Dog bite 2 mo earlier||4/5||Neg||Rabies||24 h||ND|
*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.