RABIES

Dr. Fitzroy A. Orrett, MB.BS, MSc,

D (ABMM), FCCM.
Clinical Microbiologist.
2
RABIES

“A FATAL infectious disease of the Central

Nervous System (CNS) (Encephalomyelitis) of
mammals, especially CARNIVORES,
characterized by CNS irritation, followed by
paralysis and DEATH.”
 RABIES
3

¨  Rabies is a Zoonotic disease of vertebrate animals that

can be transmitted to humans.
 RABIES
4

Rabies in Humans will be discussed under the following:

1.  Characteristics of the Rabies virus.
2.  Epidemiology and Transmission of Rabies.
3.  Pathogenesis of Rabies.
4.  Clinical Features of Rabies.

5.  Laboratory Diagnosis of Rabies.

6.  Differential Diagnosis of Rabies
7.  Treatment and Prevention of Rabies: Pre-exposure &
Post-exposure.
8.  Complications of Rabies

9.  Control of Rabies.

 RABIES
5

What are the Characteristic Features

of the Rabies Virus?
 Characteristics of the Rabies virus.
¨  Rabies virus is a bullet-shaped, ss RNA, bi-layered enveloped
6 virus belonging to the genus Lyssavirus.
¨  Measures 75 nm x 180 nm; MW = 4.6 X 106 Daltons.
¨  Regularly spaced knob-like spikes (6-7 nm long) cover the
surface, except at the flat end.
 Characteristics of the Rabies virus
(cont’d).
7

¨  The viral genome encodes 5 proteins:

¨  L, NS → are both RNA-dependent RNA polymerases

¨  N → Ribonucleoprotein

¨  M → Matrix membrane proteins (non-glycosylated)

¨  G → Glycosylated membrane proteins

¨  Aggregations of L, NS, and N proteins in the cytoplasm

of rabies-infected cells comprise Negri bodies (the
characteristic histopathologic findings of Rabies virus
infection.
 Characteristics of the Rabies virus
(cont’d)
8
¨  Virus has a negative-sense RNA → positive-sense RNA
(m-RNA) → viral proteins.
¨  Rabies virus can be inactivated by:

¤  1% soap, detergent,

¤  Formalin, ether,
¤  β-propiolactone,

¤  at pH < 3 and pH > 11.

¤  UV and X-Ray irradiation, Sunlight, Desiccation

¤  Rabies virus is stable if frozen at – 70 degrees Celsius, or
freeze-dried and held at 0-4 degrees Celsius.
 Rabies
Multiplication: Virus enters cell by fusion and is
9
uncoated in the cytoplasm:
 Epidemiology of Rabies:
10

Rabies is a Zoonotic disease prevalent in wildlife. The main

animals involved differs from region to region:
Europe: Red Fox, Bats.
Middle East: Wolf, Dog
Asia: Dog, Jackal
Africa: Dog, Mongoose, Antelope, Jackal
North America: Fox, Skunk, Raccoon, Insectivorous Bat
Caribbean: Mongoose, Bats, Dogs.
South America: Dog, Vampire Bat
Rabies is not found in Australia and Antarctica.
 Rabies
11

Epidemiology of Human Rabies:

 Epidemiology of Rabies:
12

Rabies causes about 55,000 deaths annually worldwide (1),

with 95% occurring in Asia and Africa (2). About 97%
human Rabies cases result from dog bites (3). In the USA,
animal control and vaccination programs have effectively
eliminated domestic dogs as reservoirs of Rabies (4).
Reports from several countries in 2010, showed that
Rabies carried by terrestrial animals, have been
eliminated entirely in those countries(5).
Rabies in Caribbean Mongoose present in Puerto Rico,
Cuba, Dominican Republic, Haiti and Grenada.
Rabies in Caribbean Bats present in Cuba, Grenada, Haiti
and Trinidad.
 Rabies-free countries (in green) as of
2010
13

Chile, Uruguay, Iceland, UK, Germany, Belgium, Australia, Tasmania, New

Zealand, Japan, Scandinavia
 Rabies
14

Pathogenesis of Human
Rabies.
 Pathogenesis of Human Rabies
¨ 
15
Transmission is via:
….. Saliva from bite of infected animal.
….. Aerosols (Bat caves)
….. Direct Implantation. (Transplantation of infected tissue)

¨  Following inoculation (bite of an infected animal), the virus

enters and replicates within the striated muscle or connective
tissue at the bite site.

¨  The virus then enters the peripheral nerves via Acetylcholine
receptors and migrates slowly to the CNS in the endoneurium of
the Schwann cells, causing Acute Viral Encephalitis.
¨  This migration can be blocked by local anesthetics.

¨  Rabies is approximately 100% fatal. Survivors are permanently

brain dead!
 Pathogenesis of Rabies
(cont’d)
16

¨  Multiplication within the CNS → → clinical disease.

¨  Centrifugal spread then occurs to many organs

e.g. heart, skeletal muscles, hair follicles, cornea,
taste buds, milk, sebaceous glands, liver,
lungs and skin.

¨  The cytopathology of Rabies shows → congestion of

meningeal vessels, perivascular cuffing and tissue
necrosis. Principal damage is to the limbic system.
17
 Rabies
18

Clinical Features of Human

Rabies
 Clinical Features of
Human Rabies
19

¨  Four stages of Rabies are recognized in Humans.

¨  Incubation period: 5 days to more than 2 years.
¨  Period of incubation depends on:
(a) The Bite Site (head or extremity)
(b) Severity of the bite
(c) Quantity of virus inoculated.
 Clinical Features of
Human Rabies
20

1. Prodromal Phase (2-10 days).

2. Acute Neurologic Phase
3. Coma (4-10 days after onset of
symptoms.
4. Respiratory Arrest >>>>Death
 Clinical Features of Rabies (cont’d)
Most cases occur in males < 15 years of age.
21
….. Asymptomatic
….. Prodrome: lasts from 2 – 10 days. Virus invades the
CNS (limbic system, spinal cord, brain stem).
These initial symptoms of Rabies are non-specific and
consists of
Respiratory symptoms: cough, sore throat
Gastrointestinal symptoms: abdominal pain, nausea,
vomiting, diarrhoea
Behavioural and Emotional symptoms: anxiety,
apprehension. There’s also fever, chills and malaise.
All theses symptoms often lead to an initial diagnosis of
common respiratory or gastrointestinal infections.
 Clinical Features of Rabies (cont’d)
The Prodromal Phase lasts for 2-10 days, and is followed
22
by the
Acute Neurologic Period ( 2 – 7 days). Widespread
infection of the brain with objective signs of CNS
involvement. Marked hyperactivity, with disorientation,
hallucinations, seizures, bizarre behavior, neck stiffness, or
paralysis. The hyperactivity characteristically is
intermittent with 1-5 mins periods of agitation, thrashing,
running, biting; alternating with periods of calm.
Hyperactive episodes may occur spontaneously, or
precipitated by tactile, auditory or visual stimuli. Attempts
at drinking are followed by spasms of the pharynx and
larynx which provoke chocking, gagging and fear
(Hydrophobia).
 Clinical Features of Rabies (cont’d)

23

The acute neurologic period lasts for 2-7 days, with

longer durations during the paralytic phase.
Throughout the acute neurologic period mental
status fluctuates.
Coma: occurs 4-10 days after onset of symptoms
and lasts for hours, days or months. If untreated,
patient experiences respiratory arrest and dies.
 Clinical Features of Rabies
(cont’d)
24

Simply
Early symptoms of Rabies are:
Malaise, Headache and Fever, progressing to
Acute pain, Violent movements,
Uncontrolled excitements, Depression, and
Hydrophobia.

Finally, the patient experiences periods of Mania and

Lethargy, eventually leading to Coma and
Death!
 Clinical Features of Rabies
(Summarized)
25
 Rabies
26

What are the Complications of

Rabies?
 Complications of Rabies:
27

Most are documented during the Coma stage, and include:

Neurologic: e.g: Cerebral edema. Seizures.

Pituitary: e.g: Inappropriate secretion of ADH.

Pulmonary: e.g: Hyperventilation, hypoxemia, pneumonia

.

GIT: e.g: GIT bleeding.

CVS: e.g: Hypotension, CCF, anemia, Cardiac arrest.

Kidney: e.g: Acute Renal failure.

Death!: The final outcome of Rabies.

 Laboratory Diagnosis of Rabies:
28

No tests are currently available to diagnose Rabies

before the onset of symptoms.

(a) Ante-mortem
(b) Post-mortem
 Laboratory Diagnosis of Rabies
29

Ante-Mortem
No single test is sufficient to diagnose Rabies ante
mortem. Tests are performed on samples of:
¤  Saliva: Reverse transcription followed by PCR (RT-PCR)
¤  Serum, CSF for Rabies neutralizing antibodies.
¤  Skin biopsy of hair follicles from nape of neck, corneal
smear: Fluorescence antibody (DFA) test for evidence of
Rabies antigens.
¤  Virus isolation: (Tissue culture: Murine
Neuroblastoma Cells)
 Laboratory Diagnosis of Rabies
30

Post-Mortem

Specimen: Biopsy of Brain tissue

¤  Negri bodies
¤  Virus isolation
¤  DFA
 Differential Diagnosis of Rabies
31

¡  INFECTIOUS DISEASES

e.g. Encephalitis due to Herpes viruses
(HSV, VZV), and the West Nile virus.

¡  NON-INFECTIOUS DISEASES e.g. SLE.

 Management and Prevention of
Rabies
32

(i) Pre-exposure Prophylaxis (Vaccine)

(ii) Post-exposure Prophylaxis
…Local wound treatment
…HRIG
…Vaccination
 Pre-exposure Prophylaxis for Rabies
(Immunization)
33

Inactivated Rabies vaccine is given to:

1. Persons travelling to areas where Rabies is common in
domestic animals: e.g. India, Asia, Africa, Mexico, some
Central and South American countries.

2. Persons with extensive outdoor activities (e.g. Spelunkers) or

certain professionals: e.g. Veterinarians, animal handlers,
field biologists, Laboratory workers.

3 doses of Vaccine on Days 0, 7, 21 or 28. Booster

annually or bi-annually depending on risk factor.
 Rabies
34

Vaccines available for humans are inactivated whole cell Rabies virus vaccines.

1. Nervous Tissue Preparation (Semple Vaccine). This vaccine is

associated with the rare complication of demyelinating
allergic encephalitis (DAE).
2. Human Diploid Cell Vaccine (HDCV).
3. Purified Chicken Embryo Cell Vaccine.
4. Purified Vero Cell Rabies Vaccine

A Recombinant Vaccine called V-RG has been successfully used in Belgium,

France, Germany and the USA to prevent outbreaks of Rabies in undomesticated
animals.
 Post-Exposure Prophylaxis
35
For maximum effectiveness, all 3 component of the
following must be done.

1.  Wound Treatment: Wash wound thoroughly with soap

and water.
2.  Passive immunization with HRIG. Dose = 20IU/kg
body weight. For e.g. if patient weighs 75 kg (165lb),
total dose = 1500 IU. Infiltrate half around wound
site; the rest into the deltoid muscle.
3.  Vaccination: HDCV (dose 1 ml) on days: 0, 3, 7, 14,
28.
 Post-exposure (Treatment)
(i) 
36 (a) Induced Coma:
In 2004, an US teenager, Jeanna Giese survived an
infection of Rabies unvaccinated. She was placed in an
induced coma upon onset of symptoms, and given
Ketamine and Midazolam and the antiviral drugs
Ribavirin and Amantadine. The doctors induced the
coma based on the hypotheses that detrimental
effects of Rabies were caused by temporary
dysfunctions in the brain, and these effects could be
avoided by inducing a temporary partial halt in
brain function that would protect the brain from
damage, while giving her immune system time to
defeat the virus. This treatment regimen became
known as the “Milwaukee Protocol.”
 Post-exposure (Treatment)
37

(b) Artificially increasing permeability of the Blood

Brain Barrier (BBB) with Immune Effector Cells, to
allow most immune cells to cross the BBB, thereby viral
clearance from CNS. (Hooper, et al: J Virol, 2007).
 Rabies
38

How Can Rabies be Controlled?

 Control of Rabies
URBAN:
39 Canine rabies accounts for approximately 99% of human rabies.
Control measures against canine rabies include:
… Stray dog control
… Vaccination of dogs, cats, and other pet animals
… Quarantine of imported animals.
… Not handling wild animals or strays
… If bitten by an animal (dog), washing wound with soap and water for
5-10 mins. After this, wash site with alcohol or iodine solution.
WILD ANIMALS:
More difficult to control than canine. On-going trials in
Europe where bait-containing rabies vaccine is given to foxes.
Success has been reported in Switzerland.
 References
40

1. "Rabies". World Health Organization (WHO).

http://www.who.int/mediacentre/factsheets/
fs099/en/
2.  http://www.who.int/rabies/en/
3. 
"New Rabies Vaccine Shows Promise for
Prevention, Treatment".
http://www.voanews.com/english/archive/
2009-07/2009-07-08-voa62.cfm?
CFID=316132061&CFTOKEN=85235355.
 References (cont’d)
41

4."Rabies in the U.S.".

Centers for Disease Control and Prevention (CDC).
April 22, 2011.
http://www.cdc.gov/rabies/location/usa/index.html.

5. Dr Charlie Easmon (2009-08-18). "Rabies". netdoctor.

http://www.netdoctor.co.uk/travel/diseases/
rabies.htm.
 RABIES
42

End of Lecture

Dr. Fitzroy A. Orrett, MB.BS, MSc, Dip Bact, D (ABMM),

FCCM.
Senior Lecturer, Microbiology
Department of Paraclinical Sciences
Faculty of Medicine
The University of the West Indies
St. Augustine Campus.