Clinical Review Lesson of the week

Paralytic rabies after a two week holiday in India

BMJ 2005; 331 doi: http://dx.doi.org/10.1136/bmj.331.7515.501 (Published 01 September 2005) Cite this as: BMJ 2005;331:501
  1. Tom Solomon, MRC senior clinical fellow (tsolomon@liv.ac.uk)1,
  2. Denise Marston, research scientist2,
  3. Macpherson Mallewa, Wellcome Trust clinical training fellow1,
  4. Tim Felton, specialist registrar4,
  5. Steve Shaw, consultant neuroanaesthetist3,
  6. Lorraine M McElhinney, senior research scientist2,
  7. Kumar Das, consultant neuroradiologist3,
  8. Karen Mansfield, research scientist2,
  9. Jane Wainwright, locum consultant neurologist4,
  10. Georges Ng Man Kwong, consultant physician4,
  11. Anthony R Fooks, head2
  1. 1 Viral CNS Infections Group, Divisions of Neurological Science and Medical Microbiology, University of Liverpool, Walton Centre for Neurology and Neurosurgery, Liverpool L9 7LJ
  2. 2 Rabies and Wildlife Zoonoses Group, Veterinary Laboratories Agency (Weybridge), Weybridge, Surrey KT15 3NB
  3. 3 Walton Centre for Neurology and Neurosurgery NHS Trust
  4. 4 Pennine Acute Hospitals NHS Trust, Fairfield Hospital, Bury BL9 7TD
  1. Correspondence to: T Solomon

    Introduction

    Rabies is an acute infection of the central nervous system (CNS) and caused by rabies virus or related members of the genus Lyssavirus, family Rhabdoviridae.1 The virus is usually transmitted through a dog bite and produces one of the most important viral encephalitides worldwide, with at least 40 000 deaths reported annually.2 However, it is rare in the United Kingdom, where just 12 cases have been reported since 19773: 11 were imported from overseas, and one occurred in a bat handler infected in Scotland with European bat lyssavirus type 2a.4 Most UK patients presented with furious rabies, which is characterised by hydrophobia and spasms. We report a case of paralytic rabies in a tourist after a two week holiday in Goa, India.

    Fig 2

    Phylogenetic tree depicting the relation between the rabies virus sequence amplified from our patient (RV1964—boxed) and other viruses originating in Asia. The horizontal branch lengths represent the extent of difference between the strains (expressed as nucleotide substitutions per nucleotide site), and the closer viruses are on the tree, the more closely they are related

    Case report

    A woman in her late 30s was admitted to her local general hospital under the orthopaedic surgeons, with lower back pain radiating to the left leg. The pain had started four days earlier, was severe and shooting in nature, and was getting worse. She had been seen twice in casualty in the preceding days, and by the time of admission she was unable to walk. She also had a headache and had vomited once. Three and a half months before admission, during a two week holiday to Goa, India, she had been bitten by a dog; she was walking in the street when a puppy on a lead nipped her on the left leg. There was a slight …

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