Survival after treatment of Rabies with Induction of Coma

Thanks to advances in medicine, the once present fear of rabies as a disease shielded by the immunity acquired through immunizations. If acquired without antibody resistance, a rabies infection followed by medical treatment can prolong death to 133 days after symptom onset, and seven to nine days without medical treatment.  There have been 5 instances of survival of rabies when administered immunoprophylaxis, yet the induction of a coma to allow the native immune response to wrid the body of the virus has shown effectiveness in one particular incidence.

A 15 year old patient contracted rabies through a laceration to the hand from a bat.  The subject continued normal life activities without seeking medical treatment or prophylaxis. Symptoms began one month after contact with the bat beginning with general fatigue, and abnormal sensations from the left hand. By the fourth day, blurred vision, weakness of the left leg, and gait abnormalities were present. On the fifth day symptoms progressed to fever, slurred speech, tremors, involuntary eye movements.  Patient began salivating, with uncoordinated swallowing and worsened symptoms. Upon positive identification of rabies, the patient was offered an untested treatment of antiviral drugs, and antiexcitatory drugs, with supportive care. Ketamine, and Midazolam were administered to slow neural functioning and avoid the catecholamine storm which would otherwise harm the brain, Oxygen was administered to maintain hemoglobin levels. Heparin was administered to avoid the onset of blood clotting. Ribavirin was administered as an antiviral therapy. Burst suppression was induced through high levels of benzodiazepines, and barbituates. On the tenth day of hospital treatment, a lumbar puncture indicated heightened levels of rabies antibodies.  The withdrawal of the induced coma, along with a clinically adapted reduction in sedative drugs occurred for 31 days, with effects of fever and decreased responsiveness and alertness present yet diminishing over time.  Rehabilitation occurred following when patient was considered cleared of transmissible rabies on the 31st day until the 76th day.  In a clinical visit on the 131st day patient interacted with examiner, was able to attend school part time, and had constant buccolingual choreoathetosis, a lurching gait, and fine motor difficulties.

While the patient still encounters difficulties, the treatment was a success, which allowed the immune response to develop antibodies to the viral infection while sparing the brain from a “neurotransmitter imbalance” also described as a catecholamine storm, and autonomic failure which typically results in death.

N Engl J Med 2005; 352:2508-2514

http://www.nejm.org/doi/full/10.1056/NEJMoa050382#t=article

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