Abstract
Rabies in pregnancy is rare with a high mortality. We report a pregnant woman who developed urban rabies from the bite of an infected dog. An emergency Cesarean section was performed at 31 weeks of gestation, and a premature baby was delivered who survived and did not develop rabies. The mother, however, suffered a rapid clinical deterioration and was admitted to intensive care where a Milwaukee protocol was followed. The patient survived 19 months but developed severe neurological sequelae secondary to rabies encephalitis and finally died of respiratory failure.
Case report
A 27-year-old pregnant woman was bitten on the thumb of her right hand by a dog in Lampa province, Puno department, Peru. The dog died two days later and was diagnosed with rabies by direct fluorescent antibody test (dFA) and biological assay by inoculation in mice. Our patient received wound care and five doses of rabies vaccine. On September 9, 2015, 28 days after being bitten, she was referred to the tertiary hospital, Carlos A Seguin Escobedo, in southern Peru, presenting with paresthaesiae and pain extending to the right shoulder, with persistent fever and vomiting.
Despite this treatment, her neuropathy worsened with dysphagia and respiratory failure, for which she was mechanically ventilated. The ‘Milwaukee protocol’ (MP) was applied, initiating coma with midazolam and fentanyl. The diagnosis of rabies encephalitis was confirmed by rapid fluorescent focus inhibition test (RIFFT) on her cerebrospinal fluid.
A decision was taken to deliver her baby at 31 weeks’ gestation. A premature male infant weighing 2060 g was born with an Apgar score of 5 at 1 min, 7 at 5 min and 9 at 10 min. His respiratory distress recovered with oxygen therapy. He survived and presented no symptoms or signs of rabies.
The mother remained in an induced coma for 16 months, during which time she developed numerous ventilator-associated pneumonic episodes. She was subsequently discharged with a tracheostomy and feeding gastrostomy in place for home-based care. She needed repeated readmission owing to complications and finally died of respiratory failure (22 April 2017) 19 months later.
Discussion
Human rabies is preventable. Canine rabies is currently a significant endemic public health problem in southern Peru. There is little evidence on the effectiveness of treatment. 1
The MP was used in this patient; it has been used in other cases of human rabies in Peru. Two male patients with wild rabies so treated unfortunately died 84 and 26 days after initiating the protocol. 2 However, a 42-year-old female patient survived without neurological sequelae. 3 In general, the protocol has had a low success rate, and there is controversy about its usefulness. Nonetheless, despite its low success rate, the MP has been repeatedly chosen for the treatment of clinical rabies. 4
A review of the literature revealed 16 published cases of pregnant women with rabies, mostly from Africa and Asia with fatal outcome, all of whom underwent Cesarean section or vaginal delivery of their babies. Only one had reported vertical transmission; the others did not develop rabies, whether they received post-exposure prophylaxis or rabies immune globulin or not. 5
In conclusion, we express our doubts concerning the ‘Milwaukee protocol’. Nonetheless, this allowed her to survive long enough to deliver her baby.
Footnotes
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
