Acute Respiratory Distress Syndrome Associated With Rabies: A Case Report

Abstract

Acute respiratory distress syndrome (ARDS) is the first potentially lethal complication in rabies virus infection, although its occurrence is rare. We report on a fatal case of rabies virus infection in a 45-year-old woman from Hu-Nan Province, China. The neurologic signs of limb numbness and water phobia occurred from 61 days after the dog bite; the clinical course was progressive, with the most severe clinical manifestations being fever, encephalitis, and ARDS. The woman expired 12 days after admission to the hospital. An autopsy proved rabies encephalitis, mainly involving the medulla oblongata, the thalamus, part of the pons, the cerebellum, and the hippocampus. The lung pathologic examination revealed the organizing phase of ARDS with diffuse alveolar damage, hyaline membrane formation, type II alveolar cell hyperplasia accompanied by proliferation of fibroblasts and infiltration of mononuclear cells into the interstitial space. Immunohistochemistry stain and reverse transcription-polymerase chain reaction for rabies virus failed to demonstrate the organism in the lung tissue. Strong expression of inducible nitric oxide synthase (iNOS) was detected in the alveolar macrophages. An immunologic mechanism with iNOS expression in the absence of direct invasion of the organism may participate in the pathogenesis of ARDS associated with rabies.

Involvement of extraneural tissues and upregulation of inducible nitric oxide synthase after experimental infection with rabies virus in BALB/c mice and LEW/SsN rats

“…Previously, we reported rabies‐associated acute respiratory distress syndrome (ARDS) in a 45‐year‐old woman 11,12 . Besides the established pathological features of rabies encephalitis, myocarditis and interstitial pneumonitis have also been found in this patient.…”

“…Rabies virus (Genotype 1; Accession AY431027) was isolated from a human brain tissue (origin of street rabies virus strain) and expanded via several passages in mouse brain 11,12 . This strain was cultured in neuroblastoma clone 18 with RPMI 1640 medium (Gibco, Grand Island, NY, USA) containing 10% fetal bovine serum (Gibco, Grand Island, NY, USA).…”

“…Antigen retrieval was done by boiling the tissue sections in 10 mM citric acid monophosphate buffer (pH 6.0) for 10 min in a microwave oven 12,19 . The cooled sections were immersed in 3% hydrogen peroxide in PBS with 0.05% Tween 20 (PBST) for 15 min to eliminate the endogenous peroxidase activity.…”

“…Besides the established pathological features of rabies encephalitis, myocarditis and interstitial pneumonitis have also been found in this patient. Upon immunohistochemical (IHC) examination, the rabies virus antigens were detected in the CNS, sympathetic ganglion, submucosal ganglion of esophagus, and tubular epithelium of the kidney 11,12 . In addition, inflammatory reactions of extraneural organs have been observed in human rabies in post‐mortem study 9,10 .…”

Rabies in China: An Update

“…Rabies has also been reported in Hong Kong, Marco, and Taiwan (Wong et al 1987, Hsu et al 2006. For example, five human rabies cases were reported in Hong Kong between 1980and 1984(Wong et al 1987.…”