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Cohen R, Babushkin F, Shapiro M, Uda M, Willoughby RE, et al. (2016) Paralytic Rabies Misdiagnosed as Guillain-Barre Syndrome in a Guest Worker: A Case Report. J Neuroinfect Dis 7:208. doi:10.4172/2314-7326.1000208 Copyright: ? 2016 Cohen R, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
| Keywords |
| Rabies; Emigration and immigration; Diagnostic errors; Guillain-Barr? syndrome |
| Background |
| Animal rabies is still endemic in Israel, with an average of 35 laboratory-confirmed cases per year during 2002-2012 [1]. Nevertheless, human rabies is extremely rare in Israel, with only 4 human cases diagnosed since 1961; the last was reported in 2003 [2]. All were autochthonous, one was bitten by a cat and the other two were bitten or scratched by an unidentified small mammal [3]. Paralytic rabies, an atypical presentation of rabies manifested initially by an ascending pure motor weakness, may lead to late or misdiagnosis of rabies [4], and has never been reported from Israel. |
| Israel has a large and diverse migrant population; many arrive from countries with endemic rabies. We present a case of paralytic-type human rabies in a foreign guest worker, misdiagnosed initially as Guillain-Barr? syndrome (GBS) variant and mistreated as such. |
| Case Report |
| A previously healthy 32-year-old female from India arrived in Israel on September 23rd 2014 to nurse an elderly couple. Upon arrival, she appeared ill, and was fired from her work after 5 days because of outbursts of rage and emotional instability. On October 1st she was examined by a general practitioner because of sore throat, abdominal pain, vomiting, diarrhea and leg weakness. On October 13th she was brought by an ambulance to the emergency room (ER) with fever, diffuse muscle pain, dizziness, diarrhea, vomiting and severe back pain. Initial vital signs were temperature of 36.8?C, heart rate of 100 bpm and blood pressure of 122/84 mmHg. Physical examination was normal except for diffuse abdominal tenderness. Complete blood count showed 6,400 white blood cells per microliter and platelets of 154,000 K/μL. Liver and kidney function were normal and she had mild hyperglobulinemia. |
| Venous blood gases were normal. She was treated with metoclopramide and intramuscular ibuprofen and discharged with a diagnosis of acute gastroenteritis. The following day she returned to the ER because of severe lower back and neck pain, recurrent vomiting and episodic dyspnea. She was admitted to an internal medicine ward. On admission she was afebrile and had normal vital signs. Physical examination was normal except for anxiety and agitation. An episode of choking while trying to drink water was noted but there was no hydrophobia. Blood count and chemistry were similar to the previous tests. On the following day, neurological examination found repeated episodes of rapid breathing and motor agitation; she was observed trying to sit in bed, crying and desperate. She was alert oriented to self and place but not to time. |
| There was no neck stiffness and cranial nerves were intact. Tone was overall flaccid, with normal strength in arms and reduced strength in her right leg, especially in the proximal muscles. Areflexia of all four limbs was noted. Plantar reflexes were normal. The summary of the neurologist examination was psychomotor agitation and acute generalized areflexia with hypotonia. Meningoencephalitis with central and peripheral involvement was suspected and emergency brain computerized tomography (CT) followed by a diagnostic lumbar puncture were ordered. CT was normal except for suspected lacunar infarcts in the lower left basal ganglia.... |