Human Rabies -- Connecticut, 1995

On October 3, 1995, a 13-year-old girl who resided in Greenwich, Connecticut, died from rabies virus infection. This was the first case of human rabies reported in a Connecticut resident since 1932. This report summarizes the investigation of this case, which indicated a bat as the probable source of her exposure.

On September 18, the patient reported general fatigue, stiffness, tremors, and tingling in her left arm and hand. On September 22, she visited a local emergency department because of pain and tingling in her left arm and shoulder and a low-grade fever. Cervical radiculopathy was presumptively diagnosed and was attributed to her habit of carrying a heavy backpack; ibuprofen was prescribed. She was given a cervical collar and referred to a pediatric neurologist.

On September 25, because of continuing symptoms, she was evaluated by her pediatrician, who noted sensory changes on the left arm and face. She was again referred to a pediatric neurologist and, later that day, was admitted to a hospital because of complaints of fever, neck pain, and painful sensations along her left arm and left side of her face. On physical examination, her temperature was 100.0 F (37.8 C), and she was alert but anxious; there was moderate nuchal rigidity. The only abnormal neurologic finding was deviation of the uvula to the left. Laboratory findings included a peripheral white blood cell (WBC) count of 13,600/mm3 (normal: 5000-10,000/mm3) with 86% neutrophils, 10% lymphocytes, and 4% monocytes. Her cerebrospinal fluid (CSF) contained 2 red blood cells/mm3 (normal: 0/mm3) and 100 WBCs/mm3 (normal: 0-5/mm3) with 48% neutrophils, 40% lymphocytes, and 12% monocytes, total protein of 104 mg/dL (normal: less than 40 mg/dL), and glucose level of 53 mg/dL; serum glucose was 102 mg/dL (normal: 70-110 mg/dL).

The diagnosis on admission was possible Lyme meningoencephalitis with peripheral nerve involvement; treatment was initiated with intravenous ceftriaxone and dexamethasone. During the 24 hours following admission, she became intermittently drowsy then agitated, and occasionally was disoriented. Subsequent manifestations included deviation of her tongue to the right, anisocoria, and progressive weakness of the left arm. She also was observed to be apprehensive and had difficulty swallowing, accompanied by a prominent aversion to oral intake. Severe pharyngeal spasms were elicited by offering a drink of water. The diagnosis of rabies was considered, and the patient was placed in isolation. She became increasingly agitated; although she experienced tactile hallucinations (i.e., complaining of a sensation of insects in her mouth), she intermittently was lucid and self-reflective and apologized for her mood and hallucinations.

On September 26, the girl was transferred to the intensive-care unit, where she was intubated because of progressive bulbar dysfunction. Beginning September 27, she became progressively less responsive, and subsequently lapsed into a coma. On October 3, mechanical ventilation was withdrawn, and the patient died. No autopsy was performed.

Rabies was diagnosed on October 2 at the New York State Rabies Laboratory based on corneal impressions collected on October 1, which were positive for rabies virus by immunofluorescence, and based on rising rabies virus neutralizing antibody titers of 1:32, 1:64, and 1:512 in serum samples collected on September 25, 29, and October 2, respectively. The diagnosis was confirmed at CDC through extraction of RNA from saliva and corneal epithelia, which was reverse transcribed with rabies-specific primers and amplified using the polymerase chain reaction (PCR) assay. Nucleotide sequencing of the PCR products at CDC characterized the rabies virus as a variant associated with the silver-haired bat, Lasionycterus noctivagans.

The girl lived in a single-family dwelling in a wooded residential area in Greenwich. Although she denied a history of animal bites, multiple potential sources of animal contact were present in the home and surrounding environment; domestic animals with which she was known to have had contact were accounted for and were well. Following the diagnosis of rabies, the girl's mother and three siblings recalled that on approximately August 19, a bat flying inside the house struck at least one person; during this time, the girl was asleep in an upstairs bedroom. Inspection of the house and surrounding property by the Greenwich Department of Health on September 29 did not identify dead animals or evidence of bats.

Because of possible percutaneous or mucous membrane contact with the girl's secretions during September 10-October 3, rabies postexposure prophylaxis was administered to 83 persons who reported probable contact with the patient's saliva: 46 health-care workers, 29 children, four family members, three family friends intimately involved in the girl's care, and one other adult.

Reported by: JL Muĺoz, MD, R Wolff, MD, A Jain, MD, J Sabino, MD, Westchester County Medical Center; G Jacquette, MD, M Rapoport, MD, Westchester County Dept of Health, Hawthorne, New York. J Lieberman, DVM, CC Baisley, BH Ward, MA, Greenwich Dept of Health, Greenwich; CR Brown, MD, Town of New Canaan, New Canaan, Connecticut; PM Stolte, AB Crowley, H Hastings, Nantucket Health Dept, Massachusetts. ML Cartter, MD, JL Hadler, MD, State Epidemiologist, Connecticut Dept of Public Health. TW French, PhD, Massachusetts Dept of Fisheries, Wildlife, and Environmental Law Enforcement, Westboro; S Kreindel, DVM, R Knowlton, Massachusetts Dept of Public Health. GS Birkhead, MD, JG Debbie, DVM, CA Hanlon, VMD, CV Trimarchi, DL Morse, MD, State Epidemiologist, New York State Dept of Health. Viral and Rickettsial Zoonoses Br, Div of Viral and Rickettsial Diseases, National Center for Infectious Diseases; Div of Field Epidemiology, Epidemiology Program Office, CDC.

Editorial Note

Editorial Note: Since the 1950s, bats have accounted for an increasing proportion of variants of rabies virus transmitted from wildlife reservoirs to humans. The rabies virus variant identified in this case, and in a case in New York in 1993 (1), is associated with the silver-haired bat, a solitary, migratory species with a preferred habitat of old-growth forest. However, in neither of these cases was a clear history of bite exposure to a bat or any other animal established. Of the 28 cases of human rabies diagnosed in the United States since 1980, this case was the 15th to be associated with bats; 10 of the virus variants obtained from these 15 persons have been characterized as a silver-haired bat variant.

Bat rabies is enzootic in the United States, and cases have been reported from all 48 contiguous states (1). In Connecticut, of the 671 bats submitted to the state laboratory for testing during 1991-1995, a total of 47 (7%) were positive for rabies. Nine of the bats diagnosed with rabies in Connecticut during 1995 were sent to CDC for viral typing. Eight of the bats were infected with a variant associated with the common big brown bat (Eptesicus fuscus) and one bat was infected with a rabies virus variant associated with red bats (Lasiurus borealis). None of the bats were identified by species. In New York state, of the 6810 bats submitted to the state laboratory for rabies testing during 1988-1992, a total of 312 (4.6%) were positive for rabies; of these, approximately 90% were from E. fuscus. Only 25 of the submitted bats were silver-haired bats, of which only two were positive for rabies virus (2).

The findings of the investigation of a recent case in Washington suggest that even apparently limited contact with rabid bats may be associated with rabies transmission (3). Because bites from bats may be very small, an exposure may not be recognized -- particularly when an unattended child may not be able to accurately relate events to an adult.

The case described in this report and reports of similar cases (1,3,4) underscore the national recommendation that, in situations in which a bat is physically present and the person(s) cannot reasonably exclude the possibility of a bite exposure, post- exposure prophylaxis should be given unless prompt capture and testing of the bat has excluded rabies virus infection.

References

1. CDC. Human rabies -- New York, 1993. MMWR 1993;42:799,805-6.

2. Childs JE, Trimarchi CV, Krebs JW. The epidemiology of bat rabies in New York state, 1988-92. Epidemiol Infect 1994;113:501-11.

3. CDC. Human rabies -- Washington, 1995. MMWR 1995;44:625-7.

4. CDC. Human rabies -- California, 1994. MMWR 1994;43:455-7.

   
   

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