Human Rabies — California, Georgia, Minnesota, New York, and Wisconsin, 2000

Morbidity and Mortality Weekly Report, Dec 15, 2000

On September 20, October 9, 10, 25, and November 1, 2000, persons who resided in California, New York, Georgia, Minnesota, and Wisconsin, respectively, died of rabies. This report summarizes the case investigations.

California

On September 15, a 49-year-old man visited a neurologist with 2 days of increasing right arm pain and paresthesias. The neurologist diagnosed atypical neuropathy (Table 1). The symptoms increased and were accompanied by hand spasms and sweating on the right side of the face and trunk. The patient was discharged twice from an emergency department but symptoms worsened. After developing dysphagia, hypersalivation, agitation, and generalized muscle twitching, the patient was admitted to a local hospital on September 16. Vital signs and blood tests were normal, but within hours he became confused. The consulting neurologist suspected rabies. Rabies immune globulin, vaccine, and acyclovir were administered. On September 17, the patient was placed on mechanical ventilation and rabies tests returned positive. Renal failure developed and the patient died on September 20. The patient did not report contact with a bat, although his wife reported that in June or July a bat had flown into their house and the patient had removed it.

New York

On September 22, a 54-year-old man who had resided in Ghana arrived in the United States, and on September 26, reported discomfort in his right lower back. During the next few days, the pain intensified and alternated with abdominal discomfort. He developed restlessness and anxiety. On September 30, he was admitted to a local hospital for suspected bowel obstruction. On examination, the patient appeared anxious and had right flank tenderness, diaphoresis, spontaneous ejaculation, soft tissue swelling of the right lumbar area, vomiting, and a temperature of 99.3 F (37.4 C). Other symptoms appeared within hours, including dysphagia, dizziness, shortness of breath, and paranoia. The patient became delirious, with frothing and agitation. On October 1, the patient had a cardiac arrest, was resuscitated, and placed on mechanical ventilation. Rabies tests were positive on October 3. After a gradual decrease in respiration, heart rate, and blood pressure, the patient died on October 9. History from the patient's emp loyer in Ghana revealed that the patient had been bitten in Ghana on his thumb and leg by his unvaccinated puppy in May.

Georgia

On October 3, a 26-year-old man developed intractable vomiting and hematemesis. At a local hospital, he was treated with antiemetic suppositories; that evening he became disoriented, combative, and had difficulty breathing. On October 5, he became hypotensive and hypoxic and was transferred to a referral hospital for ventilatory support. Examination revealed a temperature of 104 F (40 C), anisocoria, copious oral secretions, scattered bilateral pulmonary crackles, and a white blood cell count (WBC) of 46.6 cells x [10.sup.9]/L (normal: 5-10 x [10.sup.9]/L); a chest radiograph revealed bilateral diffuse alveolar densities. Broad spectrum antibiotics, including acyclovir, were initiated. On October 9, the patient developed cardiac arrhythmia, hypotension, and became combative, necessitating sedative and paralytic agent therapies. He developed respiratory and renal failure and died on October 10. Since July, the patient had been renting a room on the upper floor of an old house. He had reported to co-workers th at bats from the attic had entered his living quarters and landed on him while he slept. Investigation of the house occupied by the patient since July revealed a colony of approximately 200 Mexican free-tailed bats in the attic and openings between the attic and the patient's bedroom, bathroom, closet, and kitchen.

Minnesota

On October 14, a 47-year-old man visited a local clinic with 6 days of worsening right arm pain and parasthesias. Two days later he developed decreased right finger movement. Nerve conduction studies were consistent with carpal tunnel syndrome. On October 19, while travelling in North Dakota, the patient was admitted to a North Dakota hospital with a temperature of 103 F (39.4 C), flaccid paralysis and sensory loss in the right upper extremity, sensory loss in the mid-thoracic area, hypoesthesia and hyporeflexia in the left upper extremity, and anisocoria. Laboratory findings were normal except a WBC count of 13.8 x [10.sup.9]/L. The patient was placed on broad spectrum antibiotics. On October 20, the patient developed acute respiratory failure and was intubated. Magnetic resonance imaging was consistent with myelitis and ganciclovir was added to antibiotic coverage. He died on October 25. Three days earlier, a friend told the family that during August 11-19, the patient had been awakened by a bat on his rig ht hand. He killed the bat and was bitten in the process. The patient did not seek medical care. Investigation found in the patient's house multiple portals of entry for bats, openings between the attic and living areas, and extensive deposits of guano in the attic and living area.