The Imperative of Palliation in the Management of Rabies Encephalomyelitis

Abstract

The aim of this review is to guide clinicians in the practical management of patients suffering from rabies encephalomyelitis. This condition is eminently preventable by modern post-exposure vaccination, but is virtually always fatal in unvaccinated people. In the absence of any proven effective antiviral or other treatment, palliative care is an imperative to minimise suffering. Suspicion of rabies encephalomyelitis depends on recognising the classic symptomatology and eliciting a history of exposure to a possibly rabid mammal. Potentially treatable differential diagnoses must be eliminated, notably other infective encephalopathies. Laboratory confirmation of suspected rabies is not usually possible in many endemic areas, but is essential for public health surveillance. In a disease as agonising and terrifying as rabies encephalomyelitis, alleviation of distressing symptoms is the primary concern and overriding responsibility of medical staff. Calm, quiet conditions should be created, allowing relatives to communicate with the dying patient in safety and privacy. Palliative management must address thirst and dehydration, fever, anxiety, fear, restlessness, agitation, seizures, hypersecretion, and pain. As the infection progresses, coma and respiratory, cardiovascular, neurological, endocrine, or gastrointestinal complications will eventually ensue. When the facilities exist, the possibility of intensive care may arise, but although some patients may survive, they will be left with severe neurological sequelae. Recovery from rabies is extremely rare, and heroic measures with intensive care should be considered only in patients who have been previously vaccinated, develop rabies antibody within the first week of illness, or were infected by an American bat rabies virus. However, in most cases, clinicians must have the courage to offer compassionate palliation whenever the diagnosis of rabies encephalomyelitis is inescapable.

Utility of rabies neutralizing antibody detection in cerebrospinal fluid and serum for ante-mortem diagnosis of human rabies

“…Though recovery from rabies is consistently associated with the presence of neutralising antibodies in the blood and CSF, family members of previously vaccinated patients diagnosed with rabies must be made aware that although intensive care can prolong life, the patient is most likely to survive with multiple disabilities. These cases also underscore the urgent need for formulation of national guidelines for management of rabies cases in rabies endemic countries and the imperative of humane palliative care to minimize the suffering of those dying of this agonizing disease [32].…”

The Diagnosis, Clinical Course, Treatment, and Prevention of the Rabies Virus

“…Many patients develop phobias that will likely require seclusion in a calm, quiet room. Although there is little to no evidence of human-to-human transmission, visitors and medical professionals need to be cautious of potential contamination via the patient's secretion [61]. Dehydration is a major concern as paralytic rabies often inhibits the patient's ability to swallow and furious rabies can cause intense hydrophobia.…”

“…However, these have not been studied specifically for a rabies-induced central fever and so practitioners should be mindful of potential side effects. Additionally, these drugs are rarely available in the developing countries where RABV is most prevalent [61]. In this case, external, physical means of cooling the patient can be used as needed.…”

“…A variety of sedatives and tranquilizers are used to calm these symptoms. Because benzodiazepines are included on the WHO's list of essential medicines, they are commonly used to treat rabies-induced agitation as well as many other forms [61]. They can be administered intramuscularly, intravenously, or intrarectally as needed.…”

Special Issue: Rabies Symptoms, Diagnosis, Prophylaxis, and Treatment

“…Finally, Warrell et al [ 25 ] can be understood in a similar context as the issue discussion began—rabies can be prevented by rapid and appropriate postexposure prophylaxis, but retains the title as the entity with the highest case fatality. As such, once clinical signs manifest, frustration and futility ensue for all involved.…”