Rabies Death in Wyoming Highlights Need to Improve Public Awareness

A new case report about the death of a woman from rabies emphasizes the importance of rabies awareness and education among the public.

Alexia Harrist, MD, PhD, from the Epidemic Intelligence Service, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia, and colleagues published their report in the June 3 issue of the Morbidity and Mortality Weekly Report, highlighting missed opportunities in public health during the management of this case.

The report details the case of a Wyoming woman, aged 77 years, who died from rabies—the first Wyoming resident with confirmed rabies virus infection since the state began documenting reportable infectious diseases in 1911.

The woman had a history of mild dementia and had visited an emergency department in Wyoming after experiencing progressive weakness and ataxia over the course of about five days. She had slurred speech and was unable to stand without help. Initial magnetic resonance imaging (MRI) of the brain revealed no evidence of any acute lesions to explain her symptoms. Similarly, blood tests indicated no specific abnormalities. However, the results of urinalysis and urine culture indicated a urinary tract infection, and the patient was treated with intravenous ceftriaxone.

The woman was hospitalized but her neurological symptoms progressed and she developed respiratory failure. At this stage, a presumptive diagnosis of Guillain-Barré syndrome was made, based on the results of cerebrospinal fluid (CSF) analysis, and electromyography and nerve conduction studies. However, due to worsening respiratory failure, she was transferred to a hospital in Utah, where she became comatose. Additional MRI studies now indicated a central infiltrative process.

According to the authors, “[o]n day 8 of hospitalization, the patient’s family told clinicians they recalled that, 1 month before admission, the woman had found a bat on her neck upon waking, but had not sought medical care”. The husband had examined his wife and found no bite wounds, the authors say. “The patient’s husband subsequently had contacted county invasive species authorities about the incident, but he was not advised to seek health care for evaluation of his wife’s risk for rabies”.

Samples of the patient’s serum, nuchal skin, saliva, and CSF were then immediately forwarded to CDC for rabies virus diagnostic evaluation, and a diagnosis of rabies was confirmed. The rabies virus variant was identified as one carried by the silver-haired bat. Unfortunately, however, the woman died on day 11 of hospitalization.

Although the patient’s husband had apparently contacted county invasive species authorities about the bat incident when it occurred, he was neither told about the risk of rabies nor advised to seek medical or public health assistance.

The husband and another family member subsequently required rabies postexposure prophylaxis (PEP) because of potential contact with the patient’s saliva during the time she was infectious. The husband also needed PEP because he had handled the bat to remove it from the home when his wife had found it.

Rabies is an almost universally fatal zoonotic disease caused by Lyssavirus infection that is transmitted by an animal bite. The authors emphasize that rabies in humans is difficult to diagnose, not only because it is rare in the United States, but also because its clinical presentations are variable. “[S]ymptoms can be difficult to distinguish from Guillain-Barré syndrome,” they note.

In this particular case, the authors highlight the missed opportunities to educate the patient and her family about the risk of rabies transmission, noting that the patient and her husband “were unaware of the risk for rabies in the absence of a visible bite wound, did not seek medical evaluation, and did not receive PEP”. The authors also stress that, “[t]he reported multiple past telephone calls by the patient’s family to local authorities regarding bats represent missed opportunities to provide rabies education”.

Overall, this case demonstrates “the need to not only increase public awareness of rabies transmission risk from bat exposure, but also the need to educate public agencies outside of the public health domain to ensure that they can provide accurate information and proper referrals,” the authors conclude.

Dr. Parry graduated from the University of Liverpool, England in 1997 and is a board-certified veterinary pathologist. After 13 years working in academia, she founded Midwest Veterinary Pathology, LLC where she now works as a private consultant. She is passionate about veterinary education and serves on the Indiana Veterinary Medical Association’s Continuing Education Committee. She regularly writes continuing education articles for veterinary organizations and journals, and has also served on the American College of Veterinary Pathologists’ Examination Committee and Education Committee.