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Home Eurosurveillance Weekly Release  2004: Volume 8/ Issue 46 Article 4
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Eurosurveillance, Volume 8, Issue 46, 11 November 2004
Articles

Citation style for this article: Summer R, Ross S, Kiehl W. Imported case of rabies in Germany from India. Euro Surveill. 2004;8(46):pii=2585. Available online: http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=2585

Imported case of rabies in Germany from India

Rudolf Summer1 (Rudolf.Summer@lra-ffb.de), Stefan Ross2 and Wolfgang Kiehl3

1 Gesundheitsamt Fürstenfeldbruck, Bavaria
2 Konsiliarlaboratorium für Tollwut, Universitätsklinikum Essen, Institut für Virologie, Essen
3 Robert Koch-Institut, Berlin

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 [2].

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 [3]. 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 editorial team.

References:
  1. Robert Koch-Institut. Tollwut – ein Erkrankungsfall nach Indienaufenthalt. Epidemiologisches Bulletin 2004; 42: 362-3 (http://www.rki.de/INFEKT/EPIBULL/2004/42_04.PDF)
  2. CDC. Investigation of Rabies Infections in Organ Donor and Transplant Recipients ---- Alabama, Arkansas, Oklahoma, and Texas, 2004. Morbid Mortal Wkly Rep MMWR 2004; 53(Dispatch): 1-3. (http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5326a6.htm)
  3. Landes Krankenhaus Graz. Pressemeldung: Patient mit Tollwut. Press release, undated, 2004. (http://www.lkh-graz.at/cms/beitrag/10034007/1205921/)

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