An imported case of rabies was recently notified in Germany.
At the beginning of May 2004, a 51 year old Bavarian man became ill six weeks
after returning from a five month trip to India. He had influenza-like symptoms,
exhaustion, fever and malaise. In India, he had been living in basic conditions
and had contact with wild dogs. He had previously travelled to India in 2001,
where he had been bitten by a wild monkey.
On 6 May, the patient developed pain in his right shoulder and arm. On
7 May, he developed hydrophobia, aerophobia, and pharyngeal spasms. By 9
May, he was losing consciousness and vomiting blood. That day, on suspicion
that he was suffering from encephalitis or rabies, he was admitted to the
intensive care unit at a nearby hospital. Doctors treating the patient suspected
rabies at that point.
After admission to hospital, the patient quickly developed breathing difficulties.
While he was alive, various tests were done to try to confirm the suspected
diagnosis of rabies, but the results of these were all negative. The patient
died on 29 May. A preliminary pathological-anatomical diagnosis of rabies
was made, supported by the institute responsible for the post mortem. The
diagnosis was finally confirmed by two specialist rabies diagnostic laboratories,
using direct immunofluorescence as well as virus isolation from cell culture
of brain tissue samples.
Whether the monkey bite was the cause (there are cases in the literature
with incubation times of up to 7 years) or contact with saliva of an infected
wild dog, is unknown. This case highlights the importance for travellers
to get immunised against rabies before visiting countries where there is
widespread rabies in dogs, and to seek medical care if they are bitten/have
contact while there.
As with the case described here, it is not unusual for all diagnostic tests
for rabies, carried out while the patient is alive, to be negative. A clinically
suspected case is usually confirmed only after death by testing brain tissue
samples using direct immunofluorescence. Further tests on tissue samples
from this patient are currently still being carried out at the Bundesforschungsanstalt
für Viruserkrankungen der Tiere, Wusterhausen (German national research
laboratory for viral illnesses in animals, http://www.bfav.de/).
Isolates of the virus obtained from the patient’s tissue are being typed
and characterised using monoclonal antibodies. The viral RNA is also being
sequenced; this will allow geographical location of the virus, and identification
of the animal species that infected the man.
Rabies is unlikely to be spread from person to person. There have been
very few reported cases; all of which occurred when a patient had donated
organs while incubating rabies, or after death from unrecognised rabies
The very real danger to travellers to exotic destinations was reinforced
with the recent case in an Austrian man who was bitten by a wild dog on
a beach in Morocco at the beginning of August 2004, and who died in hospital
in Austria at the end of that month . A particularly high risk of rabies
exists in India (India reports at least 20 000 human deaths from rabies
per year) and Nepal.
This article was translated and adapted from reference 1 by the Eurosurveillance