Recovery of a Patient from Clinical Rabies --- Wisconsin, 2004
Rabies is a viral infection of the central nervous system, usually contracted 
from the bite of an infected animal, and is nearly always fatal without 
proper postexposure prophylaxis (PEP) (1). In October 2004, a previously healthy 
female aged 15 years in Fond du Lac County, Wisconsin, received a diagnosis of 
rabies after being bitten by a bat approximately 1 month before symptom onset. 
This report summarizes the investigation conducted by the Wisconsin Division 
of Public Health (WDPH), the public health response in Fond du Lac County, and 
the patient's clinical course through December 17. This is the first 
documented recovery from clinical rabies by a patient who had not received either pre- 
or postexposure prophylaxis for rabies. 
While attending a church service in September, the girl picked up a bat after 
she saw it fall to the floor. She released the bat outside the building; it 
was not captured for rabies testing, and no one else touched the bat. While 
handling the bat, she was bitten on her left index finger. The wound was 
approximately 5 mm in length with some blood present at the margins; it was cleaned 
with hydrogen peroxide. Medical attention was not sought, and rabies PEP was not 
administered. 
Approximately 1 month after the bat bite, the girl complained of fatigue and 
tingling and numbness of the left hand. These symptoms persisted, and 2 days 
later she felt unsteady and developed diplopia (i.e., double vision). On the 
third day of illness, with continued diplopia and onset of nausea and vomiting, 
she was examined by her pediatrician and referred to a neurologist. At that 
time, the patient continued to have blurred vision and also had partial 
bilateral sixth-nerve palsy. Magnetic resonance imaging (MRI) with and without 
contrast and magnetic resonance angiography (MRA) studies of her brain were normal, 
and the patient was sent home. 
On the fourth day of illness, the patient's symptoms continued, and she was 
admitted to a local hospital for lumbar puncture and supportive care. On 
admission, she was afebrile, alert, and able to follow commands. She had partial 
sixth-nerve palsy, blurred vision, and unsteady gait. Standard precautions for 
infection control were observed. Lumbar puncture revealed a white blood cell 
count of 23 cells/µL (normal: 0 cells/µL) with 93% lymphocytes, a red blood cell 
count of 3 cells/µL (normal: 0 cells/µL), a protein concentration of 50 mg/dL 
(normal: 15--45 mg/dL), and a glucose concentration of 58 mg/dL (normal: 
40--70 mg/dL). During the next 36 hours, she had slurred speech, nystagmus, tremors 
of the left arm, increased lethargy, and a temperature of 102oF (38.9oC). 
On the sixth day of illness, the bat-bite history was reported, and rabies 
was considered in the differential diagnosis. The patient was transferred to a 
tertiary care hospital. Because rabies was recognized as a possibility, 
expanded infection-control measures, including droplet precautions and one-to-one 
nursing, were instituted at time of transport. On arrival, the patient had a 
temperature of 100.9oF (38.3oC), impaired muscular coordination, difficulty 
speaking, double vision, muscular twitching, and tremors in the left arm. She was 
somewhat obtunded but answered questions appropriately and complied with 
commands. 
Blood serum, cerebrospinal fluid (CSF), nuchal skin samples, and saliva were 
submitted to CDC for rabies testing. MRI with and without contrast and 
angiogram/venogram sequences were normal. She had hypersalivation and was intubated. 
Rabies-virus--specific antibodies were detected in the patient's serum and 
CSF. Direct fluorescent antibody staining of nuchal skin biopsies was negative 
for viral antigen, and rabies virus was not isolated from saliva by cell 
culture. Rabies-virus RNA was not detectable by reverse transcriptase polymerase 
chain reaction assay of either sample. Therefore, identification of the virus 
variant responsible for this infection was not possible. 
Clinical management of the patient consisted of supportive care and 
neuroprotective measures, including a drug-induced coma and ventilator support. 
Intravenous ribavirin was used under an investigational protocol. The patient was 
kept comatose for 7 days; during that period, results from lumbar puncture 
indicated an increase in antirabies IgG by immunofluorescent assay from 1:32 to 
1:2,048. Her coma medications were tapered, and the patient became increasingly 
alert. On the 33rd day of illness, she was extubated; 3 days later she was 
transferred to a rehabilitation unit. At the time of transfer, she was unable to 
speak after prolonged intubation. As of December 17, the patient remained 
hospitalized with steady improvement. She was able to walk with assistance, ride a 
stationary cycle for 8 minutes, and feed herself a soft, solid diet. She solved 
math puzzles, used sign language, and was regaining the ability to speak. The 
prognosis for her full recovery is unknown. 
To provide community members accurate information about rabies and its 
transmission, local and state health officials held a press conference on October 
21. Public health officials and community pediatricians visited the patient's 
school to assess the need for rabies prophylaxis among students. WDPH 
distributed assessment tools to the local health department to screen health-care 
workers and community contacts of the patient for exposure to potentially infectious 
secretions. The patient's five family members, five of 35 health-care 
workers, and 27 of 55 community contacts received rabies PEP, either because of 
exposure to the patient's saliva during sharing of beverages or food items or after 
contact with vomitus. No health-care workers at the tertiary care hospital 
required PEP. Site inspection of the church revealed no ongoing risk for 
exposure to bats. 
Reported by: RE Willoughby, MD, MM Rotar, Children's Hospital