lecture on Mumps Rubella and Rabies for MBBS students

5. Neck swelling with submandibular LAP,Neck swelling with submandibular LAP,
striking erythema and edemastriking erythema and edema

7. MumpsMumps
RubellaRubella
RabiesRabiesDr Mohammad Nurul HuqDr Mohammad Nurul Huq

8. MUMPS

9. At the end of session you will learnAt the end of session you will learn
• MumpsMumps has many complicationshas many complications
• Epidemic/2–5yEpidemic/2–5y
• It is preventableIt is preventable
• CongenitalCongenital RubellaRubella is dangerousis dangerous
• It is also preventableIt is also preventable
• Non gestational rubella is mildNon gestational rubella is mild
• Cl.Cl. RabiesRabies is always lethal. It is also preventableis always lethal. It is also preventable

10. IntroductionIntroduction
 Mumps is a contagious d. c/by a pleomorphic RNA:Mumps is a contagious d. c/by a pleomorphic RNA:
paramyxovirusparamyxovirus
 Single strainSingle strain
 Incidence: 100–1k/100k/yIncidence: 100–1k/100k/y
 Anyone non-immune can get itAnyone non-immune can get it
 Before vax., it was common inBefore vax., it was common in
children and young adultschildren and young adults
 No specific Rx: supportiveNo specific Rx: supportive
EM: Mumps virus is enveloped;EM: Mumps virus is enveloped;
variable shape. Size: 120–450 nmvariable shape. Size: 120–450 nm

11. TransmissionTransmission
• Worldwide.Worldwide. HumansHumans are theare the onlyonly hosthost
• Direct contact/droplets (coughs, sneezes or talks), fomites;Direct contact/droplets (coughs, sneezes or talks), fomites;
cups or soft drink cans, contaminated handscups or soft drink cans, contaminated hands
• IPIP ~17d (12-25d)~17d (12-25d)
• PI:PI: 2d before salivary swelling to 5d after start2d before salivary swelling to 5d after start
In immunized people most parotitis are not MIn immunized people most parotitis are not M

12. CL. FEATURESCL. FEATURES
• A multi-system viremiaA multi-system viremia
• 50%50% subclinicalsubclinical
 Typical:Typical: a few days F (≥38°C), HA, myalgia, arthralgia,a few days F (≥38°C), HA, myalgia, arthralgia,
tiredness, dry mouth, anorexia: followed by swelling oftiredness, dry mouth, anorexia: followed by swelling of
salivary g.: parotids the commonest (pain, tenderness,salivary g.: parotids the commonest (pain, tenderness,
dysphagia).dysphagia). 70% unilateral; 30% bilateral70% unilateral; 30% bilateral
• 1/3 without swelling: as URTI1/3 without swelling: as URTI
• Many do not feel very illMany do not feel very ill

13.  MostlyMostly mildmild in children,in children, more severe in adults with moremore severe in adults with more
complicationscomplications
 PPeak:eak: aged 5–9yaged 5–9y
 InIn >50%: CSF pleocytosis>50%: CSF pleocytosis but <10% have CNS symptomsbut <10% have CNS symptoms
 Encephalitis and permanent neurological sequelae rareEncephalitis and permanent neurological sequelae rare
 11stst
TM of preg:TM of preg: ⇑⇑ abortionabortion
 Crosses placenta but no cong. malformationCrosses placenta but no cong. malformation
CL. FEATURES ..CL. FEATURES ..

14. Parotitis. Edematous swelling extends below the angle of mandibleParotitis. Edematous swelling extends below the angle of mandible
Normal
Full recess

15. Parotitis withParotitis with
transient necktransient neck
and presternaland presternal
edema andedema and
erythemaerythema

16. Other C/of ParotitisOther C/of Parotitis
• CMV, HIVCMV, HIV
• Parainfluenza 1, 3Parainfluenza 1, 3
• InfluenzaInfluenza
• EnterovirusesEnteroviruses
• L. choriomeningitidisL. choriomeningitidis
• S. aureusS. aureus
• Non-TB mycobacteriumNon-TB mycobacterium
Less oftenLess often
• Gram +ve/-ve bacteriaGram +ve/-ve bacteria
• Salivary calculiSalivary calculi
• Phenylbutazone,Phenylbutazone,
thiouracil, iodidesthiouracil, iodides
• Dm, cirrhosisDm, cirrhosis
• MalnutritionMalnutrition
• Mikulicz synMikulicz syn

17. DIAGNOSISDIAGNOSIS
• Mainly clinical.Mainly clinical. Salivary amylaseSalivary amylase
• Virus in saliva, throat, urine, CSFVirus in saliva, throat, urine, CSF
• Specific IgM, PCRSpecific IgM, PCR
• SignificantSignificant ⇑⇑ of sp. IgG titers between acute andof sp. IgG titers between acute and
convalescent samplesconvalescent samples

18. ComplicationsComplications
• Orchitis (Orchitis (post pubertal):post pubertal):
rare sterilityrare sterility
• DeafnessDeafness
• Arthritis (reactive)Arthritis (reactive)
• ThyroiditisThyroiditis
• MastitisMastitis
• GNGN
• MyocarditisMyocarditis
• ThrombocytopeniaThrombocytopenia
• Cerebellar ataxiaCerebellar ataxia
• Transverse myelitisTransverse myelitis
• Ascending polyradiculitisAscending polyradiculitis
• PancreatitisPancreatitis
• OophoritisOophoritis
• EndocardialEndocardial
fibroelastosisfibroelastosis
The highest risk is in males 15-29yThe highest risk is in males 15-29y

19. SupportiveSupportive
• Analgesic, antipyretic, hot moist compressAnalgesic, antipyretic, hot moist compress
OUTBREAK CONTROLOUTBREAK CONTROL
• Exclude affected students forExclude affected students for 9d9d
• Immunize all susceptibleImmunize all susceptible
• Vax., Ig/Mumps Ig not effective in the exposedVax., Ig/Mumps Ig not effective in the exposed
• Immunization during IP: noImmunization during IP: no ⇑⇑ riskrisk
TREATMENTTREATMENT

20. ISOLATIONISOLATION
Droplet precautions untilDroplet precautions until 5d5d after onsetafter onset
• No close contact to esp. babies and weak immunityNo close contact to esp. babies and weak immunity
• Stay home for 5d. Cover mouth and nose with a tissueStay home for 5d. Cover mouth and nose with a tissue
when cough/sneeze; cough/sneeze into your upper sleevewhen cough/sneeze; cough/sneeze into your upper sleeve
or elbow, not handsor elbow, not hands
• Wash hands well and frequentlyWash hands well and frequently
• Don’t share drinks or eating utensilsDon’t share drinks or eating utensils
• Regularly clean surfaces that are touched with soap waterRegularly clean surfaces that are touched with soap water

21. MUMPS VACCINEMUMPS VACCINE
• Live-attenuated,Live-attenuated, monovalent. MMR preferredmonovalent. MMR preferred
• >95% with 1 shot.>95% with 1 shot. Outbreaks may occur:Outbreaks may occur: 22ndnd
dose for:dose for:
• primary vax. failureprimary vax. failure
• permanent immunitypermanent immunity
• MMR at 9mo. 2MMR at 9mo. 2ndnd
dose at least 1mo-1y laterdose at least 1mo-1y later
• ImmunizeImmunize beforebefore puberty.puberty. No mumps vax. after ≥50yNo mumps vax. after ≥50y

22. Adverse ReactionsAdverse Reactions
• Rare:Rare: orchitis, parotitis, LGF, allergy,orchitis, parotitis, LGF, allergy, rashrash
• Very rare:Very rare: febrile fitfebrile fit, nerve deafness, rash, aseptic, nerve deafness, rash, aseptic
meningitis, encephalitis, pruritus, purpurameningitis, encephalitis, pruritus, purpura
Precautions and C.I.Precautions and C.I.
• None in minor illnesses. IfNone in minor illnesses. If seriousserious: defer: defer
• Mild allergy to components may occur. Anaphylaxis rareMild allergy to components may occur. Anaphylaxis rare
• Children with egg allergy can be immunized but not thoseChildren with egg allergy can be immunized but not those
with anaphylaxis to eggwith anaphylaxis to egg
• Immunocompromised (HIV, cancer, steroids)Immunocompromised (HIV, cancer, steroids)

23. PregnancyPregnancy
• NoNo conception for 4w. Avoid in pregnancyconception for 4w. Avoid in pregnancy
• Vax. virusVax. virus cancan infect placenta, but not fetus; vax. in preg.infect placenta, but not fetus; vax. in preg.
has not been associated with cong. malform.has not been associated with cong. malform.
Altered ImmunityAltered Immunity
AvoidAvoid in Ca, steroid Rx., chemo-, radiation etc.in Ca, steroid Rx., chemo-, radiation etc.
Exception is HIVException is HIV
Risk of M in altered immunity isRisk of M in altered immunity is ⇓⇓ by vaccinating closeby vaccinating close
contactscontacts
Immune people do not transmit M vax. virusImmune people do not transmit M vax. virus

24. • IVIgIVIg (Kawasaki D, GBS)(Kawasaki D, GBS) can inhibit response.can inhibit response. PushPush
2 w before/3 mo after Ig or BT2 w before/3 mo after Ig or BT
CorticosteroidsCorticosteroids
• 1 mo after stopping steroids (2 mg/kg/d or >201 mo after stopping steroids (2 mg/kg/d or >20
mg/day formg/day for ≥≥14 d)14 d)
• Immunosuppression: wait 3 mo after stoppingImmunosuppression: wait 3 mo after stopping
Ig Administration

25. RUBELLA

26. EPIDEMIOLOGYEPIDEMIOLOGY
• An RNA virus of Togaviridae familyAn RNA virus of Togaviridae family
• Humans only. 50% asymptomaticHumans only. 50% asymptomatic
• Direct/droplet contactDirect/droplet contact
• Mostly mildMostly mild
• Immunity from infx/vax is prolongedImmunity from infx/vax is prolonged
• IP: 2-3w (16-18 d)IP: 2-3w (16-18 d)
• PI: a few days before to 7d after rashPI: a few days before to 7d after rash
• Some CRS shed virus in NP secretions and urine for 1ySome CRS shed virus in NP secretions and urine for 1y

27. CL. MANIFESTATIONSCL. MANIFESTATIONS
Postnatal RubellaPostnatal Rubella
• MildMild
• GeneralizedGeneralized MPR, GLAPMPR, GLAP (occipital, postauricular, cx.), LGF(occipital, postauricular, cx.), LGF
• Transient polyarthritis is common in adolescents,Transient polyarthritis is common in adolescents,
especially femalesespecially females
• Encephalitis, thrombocytopenia are rareEncephalitis, thrombocytopenia are rare

28. Adenovirus and enterovirus can cause exanthem that mimics rubella. Serologic testing isAdenovirus and enterovirus can cause exanthem that mimics rubella. Serologic testing is
important if the patient is pregnantimportant if the patient is pregnant

29. Distribution isDistribution is
similar to that ofsimilar to that of
measles but lessmeasles but less
intenseintense

30. "blueberry muffin"

31. Newborn with CRSNewborn with CRS

32. Cong. Rubella Syndrome (CRS)Cong. Rubella Syndrome (CRS)
• R. in preg. can cause abortion, IUD, or a many cong.R. in preg. can cause abortion, IUD, or a many cong.
anomalies. Risk:anomalies. Risk:
• 85%85% in the first moin the first mo
• 30%30% in the 2ndin the 2nd
• 5%5% in the 3in the 3rdrd
– 4– 4thth

33. CRS triadCRS triad
• Ear:Ear: sensorineural deafnesssensorineural deafness (60%)(60%)
• Eye:Eye: retinopathy (mainlyretinopathy (mainly “salt-and-pepper"“salt-and-pepper" type),type),
cataract,cataract, microphthalmia (40%),microphthalmia (40%), glaucomaglaucoma
• Heart:Heart: PDA (50%),PDA (50%), PSPS

34. Commonest CRS anomaliesCommonest CRS anomalies
• Retinopathy, cataract, glaucomaRetinopathy, cataract, glaucoma
• PDAPDA
• DeafnessDeafness
• Behavioral disorders, MR, meningoencephalitisBehavioral disorders, MR, meningoencephalitis

35. Other CF of CRSOther CF of CRS
• HSM,HSM, micrognathia, or BM problems (may be transient);micrognathia, or BM problems (may be transient);
MR, microcephaly, LBW, FTTMR, microcephaly, LBW, FTT
• ThrombocytopeniaThrombocytopenia
• Developmental delay, learning disabilities, autism,Developmental delay, learning disabilities, autism,
schizophreniaschizophrenia
• Diabetes; radiolucent bone diseaseDiabetes; radiolucent bone disease
• Mild CRS may occurMild CRS may occur

36. "Salt-and-pepper" retinopathy is the commonest eye defect of CRS

37. CRS: PDA and bone changes

38. Longitudinal sclerotic striae (celeryLongitudinal sclerotic striae (celery
stalk) at metaphyses which arestalk) at metaphyses which are
irregular with dense bandsirregular with dense bands
(20%); most evident around(20%); most evident around
knees. Medulla is narrow (20%).knees. Medulla is narrow (20%).
Epiphyseal centers absentEpiphyseal centers absent

39. Radiolucent long bone changes
in metaphyses in CRS

41. CRS pneumonia

42. CRS: microcephaly

43. DIAGNOSISDIAGNOSIS
• Virus from nose, blood, urine, CSF, TSVirus from nose, blood, urine, CSF, TS
• Sp. IgM may beSp. IgM may be falsefalse--positivepositive;; confirm byconfirm by
stable/rising RIgG over several mo. (4-foldstable/rising RIgG over several mo. (4-fold ⇑⇑))
• Dx ofDx of CRSCRS after >1y of age is difficult: serology isafter >1y of age is difficult: serology is
not diagnostic, viral isolation is impossiblenot diagnostic, viral isolation is impossible
• ELISA, IFA, and latex agglutination can be doneELISA, IFA, and latex agglutination can be done

44. Exposure in PregnancyExposure in Pregnancy
• Immediate Ab test. RIgG indicates immunityImmediate Ab test. RIgG indicates immunity
• If negative do 2If negative do 2ndnd
test 3w latertest 3w later
• If negative, do 3If negative, do 3rdrd
test 3w after 2test 3w after 2ndnd
::
• still negative: no infx.still negative: no infx.
• positive 2positive 2ndnd
/3/3rdrd
: recent infx.: recent infx.
• Routine Ig is not recommendedRoutine Ig is not recommended
• Ig is given if termination is not wanted:Ig is given if termination is not wanted:
∀⇓⇓ clinical infx.clinical infx.
• but does not guarantee prevention of CRSbut does not guarantee prevention of CRS

46. Treatment:Treatment: SupportiveSupportive

47. DD (post natal rubella)
• MeaslesMeasles
• AdenovirusAdenovirus
• EnterovirusEnterovirus
• Drug rashDrug rash
• Scarlet feverScarlet fever
• DengueDengue
• Typhoid/typhusTyphoid/typhus

48. ISOLATION OF HOSP. PT.ISOLATION OF HOSP. PT.
• Standard droplet precautions for 7d of rashStandard droplet precautions for 7d of rash
• Contact isolation from CRS until 1y of age, or till nose,Contact isolation from CRS until 1y of age, or till nose,
throat and urine are repeatedly negative after 3 mo of agethroat and urine are repeatedly negative after 3 mo of age
School and Child CareSchool and Child Care
• All R. are excluded for 7 d of rashAll R. are excluded for 7 d of rash
• Caregivers should avoid pregnant contactsCaregivers should avoid pregnant contacts

49. VaccineVaccine
• Live attenuated; MMR preferred. 2 shots:Live attenuated; MMR preferred. 2 shots:
• prevents primary vax. failureprevents primary vax. failure
• ~ 100% seroconversion~ 100% seroconversion
• No conception within 28 d of vax.No conception within 28 d of vax.
• Can be given with other vax.Can be given with other vax.
• H/o R is not an evidence of immunityH/o R is not an evidence of immunity
ContraindicationsContraindications:: F is not a CI. Defer in serious illnessF is not a CI. Defer in serious illness
• Administration of IG:Administration of IG:
• Altered immunity :Altered immunity :
• Corticosteroids:Corticosteroids:

50. PrecautionsPrecautions in vaccinationin vaccination
• Pregnancy.Pregnancy. Avoid. If given or preg. within 28d:Avoid. If given or preg. within 28d:
• 2% fetuses develop asymptomatic R. infx., but no cong.2% fetuses develop asymptomatic R. infx., but no cong.
defects.defects. No terminationNo termination
• Immunizing children whose contacts are pregnant isImmunizing children whose contacts are pregnant is
not a risknot a risk
• Immunized people may shed vax. virus for 28d, but noImmunized people may shed vax. virus for 28d, but no
evidence of transmissionevidence of transmission

51. Adverse Reactions of vaccioneAdverse Reactions of vaccione
• Mild LAP common. F: 5-15%Mild LAP common. F: 5-15%
• Arthralgia 25% and reactive arthritis 10% 1-3w later; moreArthralgia 25% and reactive arthritis 10% 1-3w later; more
in femalesin females
• Rash 5%Rash 5%
• ThrombocytopeniaThrombocytopenia

52. IVIGIVIG
• mmay interfere immune response. R. vax. may beay interfere immune response. R. vax. may be
given to women along with anti-Rh (D) or bloodgiven to women along with anti-Rh (D) or blood
products, but testedproducts, but tested ≥≥8 w later to see8 w later to see
seroconversionseroconversion
Altered immunityAltered immunity
• No live-virus vaccine except in HIVNo live-virus vaccine except in HIV
• Immunize the close contactsImmunize the close contacts
CorticosteroidsCorticosteroids
• 1 month after HD steroids for1 month after HD steroids for ≥≥14 days14 days

53. FDA: Indications of IVIgFDA: Indications of IVIg
• Kawasaki disease, GBS, CIDPKawasaki disease, GBS, CIDP
• ITP, Pediatric HIVITP, Pediatric HIV
• Allogeneic BM transplant, CLLAllogeneic BM transplant, CLL
• ImmunodeficienciesImmunodeficiencies
• Kidney transplant with a high Ab recipient or with an ABOKidney transplant with a high Ab recipient or with an ABO
incompatible donorincompatible donor

54. Reactive ArthritisReactive Arthritis
autoimmune A. in response to an infx. in non-articular part ofautoimmune A. in response to an infx. in non-articular part of
the body, GU or GITthe body, GU or GIT (cross-reactivity)(cross-reactivity) usually by ausually by a
bacterium ("trigger”) which is cured (commonly salmonella,bacterium ("trigger”) which is cured (commonly salmonella,
shigella, campylobacter,shigella, campylobacter, C. trachomatisC. trachomatis oror N. gonorrheae)N. gonorrheae)
• <5 joints: commonly knees or sacroiliacs; may be “additive”<5 joints: commonly knees or sacroiliacs; may be “additive”
or “migratory”or “migratory”
• It is seronegative, HLA-B27-linkedIt is seronegative, HLA-B27-linked
• Age: 20–40 y, men more. More in HIVAge: 20–40 y, men more. More in HIV

55. • RA often is coupled withRA often is coupled with Reiter's Syn. ofReiter's Syn. of arthritis,arthritis,
conjunctivitis/uveitis, and urethritis in men or cervicitis inconjunctivitis/uveitis, and urethritis in men or cervicitis in
womenwomen
• +/- mucocutaneous lesions, psoriasis-like lesions like+/- mucocutaneous lesions, psoriasis-like lesions like
circinate balanitis, and keratoderma blennorrhagicacircinate balanitis, and keratoderma blennorrhagica
• Enthesitis of Achilles T can cause heel painEnthesitis of Achilles T can cause heel pain
• Features can be incompleteFeatures can be incomplete

58. Man’s best friend but not vaccinatedMan’s best friend but not vaccinated

62. Rabies
(Rhabdovirus)Rabhas means Frenzy

63. World Rabies Day (Sept. 28)
• …… to reduceto reduce
the sufferingthe suffering
from rabiesfrom rabies

64. At the end of session you will learnAt the end of session you will learn
• Rabies: an invariably fatalRabies: an invariably fatal encephalitisencephalitis. Only. Only
mammals affected.mammals affected. Always endemic in the wildAlways endemic in the wild
• VirusVirus descendsdescends from brain to salivary glandsfrom brain to salivary glands
• 90% are from rabid dog; bats spread it by aerosol90% are from rabid dog; bats spread it by aerosol
• It can be preventedIt can be prevented
• Bangladesh stands 2Bangladesh stands 2ndnd
in mortalityin mortality
• 100% preventable100% preventable

65. Key factsKey facts
• Globally >Globally >60,000 deaths/60,000 deaths/yy in >150 countriesin >150 countries
• 95% in Asia Africa95% in Asia Africa
• 50% children50% children
• India: (~30,000)India: (~30,000)
• Wound cleansing and immunization can prevent itWound cleansing and immunization can prevent it
• Bangladesh: mBangladesh: most people are unprotectedost people are unprotected
• Rabies costs the world $124 billion/yRabies costs the world $124 billion/y

66. What is Rabies?What is Rabies?
• .. a zoonosis c/by.. a zoonosis c/by rabiesrabies virusvirus
• Infects both domestic and wild animalsInfects both domestic and wild animals
• Causes ac. EncephalitisCauses ac. Encephalitis
Symptomatic rabies:Symptomatic rabies: 100% fatal100% fatal

67. Rhabdo/lyssa viruses
• Bullet shaped.Bullet shaped. RNARNA
• EnvelopedEnveloped
• Killed by ethanol ether,Killed by ethanol ether,
iodine, soap/detergents,iodine, soap/detergents,
chloroform, acetone,chloroform, acetone,
heat (60heat (6000
c x5 min)c x5 min)
Lyssa means rageLyssa means rage

68. Fixed and Street VirusFixed and Street Virus
• Fixed virusFixed virus (lab virus)(lab virus):: Rabies virus after serial passageRabies virus after serial passage
through rabbits to stabilize its virulence and IPthrough rabbits to stabilize its virulence and IP
• Street virus:Street virus: wild viruswild virus
IP: incubation periodIP: incubation period

69. EpidemiologyEpidemiology
• Primary reservoirs:Primary reservoirs: wild mammalswild mammals
• OnlyOnly mammalsmammals affected; exceptaffected; except mice !mice !
• ManMan, dogs, raccoons, skunks, foxes, bats, cats, cattle, dogs, raccoons, skunks, foxes, bats, cats, cattle
commonlycommonly affectedaffected
• It is endemic in many countries except Australia, Malaysia,It is endemic in many countries except Australia, Malaysia,
Japan, Bhutan, NepalJapan, Bhutan, Nepal

71. Distribution of rabies reservoirsDistribution of rabies reservoirs

72. RaccoonsRaccoons

73. Skunks; a major reservoir of rabies in USASkunks; a major reservoir of rabies in USA

75. • Bites, abrasionsBites, abrasions
• Scratches,Scratches, aerosol (bats)aerosol (bats)
• Mucosal exposureMucosal exposure
• RarelyRarely
• eating infected meateating infected meat
• corneal transplantationcorneal transplantation
TransmissionTransmission

76. PathogenesisPathogenesis
• IP: 9-90dIP: 9-90d (several years):(several years): depends on:depends on:
• inoculum, siteinoculum, site
• wound severity, innervationwound severity, innervation
• Untreated:Untreated: 50% rabid bites will develop R:50% rabid bites will develop R:
• virulence, dosevirulence, dose
• route, site, age, host defenseroute, site, age, host defense

77. Pathogenesis ..Pathogenesis ..
• RV replicates in muscles: enters nerves and ascends toRV replicates in muscles: enters nerves and ascends to
CNS (CNS (3 mm/h)3 mm/h)
• Spread within CNS is rapidSpread within CNS is rapid
• Then spreads centrifugally by nerves to salivary g., eyes,Then spreads centrifugally by nerves to salivary g., eyes,
kidneys, breastskidneys, breasts
• This time the classic CF developThis time the classic CF develop
RV: rabies virusRV: rabies virus

78. Pathogenesis ..Pathogenesis ..
Live virusLive virus  skin: mucosa: muscleskin: mucosa: muscle
Peripheral nervePeripheral nerve
CNS (gray matter)CNS (gray matter)
Salivary, eyes, breast, kidneysSalivary, eyes, breast, kidneys
moves centripetally
moves centrifugally

79. HistopathologyHistopathology
• EncephalomyelitisEncephalomyelitis
• Perivascular inflammatory cellsPerivascular inflammatory cells
• Neuronal cytoplasmic inclusion (Negri bodies) esp. inNeuronal cytoplasmic inclusion (Negri bodies) esp. in
pyramidal cellspyramidal cells

80. Early CF: (often vague)Early CF: (often vague)
• Flu-like:Flu-like: malaise, F:malaise, F: 38C or above38C or above, chills, HA, f, chills, HA, fatigue,atigue,
problems sleeping, anorexiaproblems sleeping, anorexia
• Anxiety, irritability, sore throatAnxiety, irritability, sore throat
• Discomfort/ paresthesiaDiscomfort/ paresthesia at bite site (50%)at bite site (50%)
• BBizarre behaviorizarre behavior
On progression:On progression: neuro-symptoms:neuro-symptoms:

81. Neuro-symptoms:Neuro-symptoms: bbroad categoryroad category
• Furious rabies (80%)Furious rabies (80%)
• Dumb or paralytic rabiesDumb or paralytic rabies
(GBS) 20%(GBS) 20%

82. Furious rabiesFurious rabies
• anxiety, confusion, insomnia, nervousness, seizure,anxiety, confusion, insomnia, nervousness, seizure,
aggressivenessaggressiveness, hallucinations, delirium, fear of death, hallucinations, delirium, fear of death
• biting, delusions, HGF, hyperhydrosis, goose skin, priopism,biting, delusions, HGF, hyperhydrosis, goose skin, priopism,
hypersalivation, dysphagia, hydrophobia (50%),hypersalivation, dysphagia, hydrophobia (50%),
aerophobia, photophobiaaerophobia, photophobia
• a few days later coma and deatha few days later coma and death

83. Dumb/paralytic rabiesDumb/paralytic rabies
• S/of partial/full paralysisS/of partial/full paralysis usually begins in the limbs andusually begins in the limbs and
spreads all overspreads all over
• Hydrophobia isHydrophobia is unusualunusual
• Progress to coma and death (heart or lung failure)Progress to coma and death (heart or lung failure)

84. A rabid dog displayingA rabid dog displaying
the classic form ofthe classic form of
paralytic R, cranial-paralytic R, cranial-
nerve deficits andnerve deficits and
hypersalivationhypersalivation

85. Routine rabies tests:Routine rabies tests:
• Direct fluorescent antibody test (dFA:) (only postDirect fluorescent antibody test (dFA:) (only post
mortem)mortem)
• Histopathology:Histopathology: NegriNegri bodies. Immunohistochemistrybodies. Immunohistochemistry
(IHC). EM(IHC). EM
Importance:Importance:
• For timely post-exposure prophylaxis (PEP)For timely post-exposure prophylaxis (PEP)
• Save a pt. from unnecessary physical and psycho. traumaSave a pt. from unnecessary physical and psycho. trauma
if the animal is not rabidif the animal is not rabid
Diagnosis in AnimalsDiagnosis in Animals

86. dFAdFA detects RVdetects RV
• Ideal tissue is nerve (brain)Ideal tissue is nerve (brain)
• Fl. anti-rabies Ab incubated with brain tissue fixes RV; seenFl. anti-rabies Ab incubated with brain tissue fixes RV; seen
by Fl. MC. Unbound Ab can be washed awayby Fl. MC. Unbound Ab can be washed away
IHCIHC
• Like dFA, IHC uses sp. Ab to detect RV inclusions in tissues.Like dFA, IHC uses sp. Ab to detect RV inclusions in tissues.
More sensitive than histopathologyMore sensitive than histopathology
Fl: fluorescence. MC: microscopeFl: fluorescence. MC: microscope

87. DFA negativeDFA negative
DFA positiveDFA positive

88. • Negri bodiesNegri bodies are pathognomonic incl. bodies in theare pathognomonic incl. bodies in the
cytoplasm of certain nerves (cytoplasm of certain nerves (only in 20%)only in 20%)

89. Rabies Dx in HumansRabies Dx in Humans
• No test available before cl. diseaseNo test available before cl. disease
• Confirmed pre- and post mortem by detecting RV, viral Ag inConfirmed pre- and post mortem by detecting RV, viral Ag in
brain, skin, urine, salivabrain, skin, urine, saliva
• Saliva is tested by reverse transcription followed by PCR (RT-Saliva is tested by reverse transcription followed by PCR (RT-
PCR)PCR)
• Antibody: serum, CSFAntibody: serum, CSF
Ag: antigenAg: antigen

90. PreventionPrevention
• Vaccinating pet and killing stray dogsVaccinating pet and killing stray dogs
• Vaccine for at risk personsVaccine for at risk persons
• No contact with stray/wild animalsNo contact with stray/wild animals
• Not touching animal carcassesNot touching animal carcasses
• Don’t capture or provoke stray animalsDon’t capture or provoke stray animals
• Secure garbageSecure garbage
• Cover chimneys and other entrancesCover chimneys and other entrances

91. • If bitten by bats, skunks, foxes, other carnivoresIf bitten by bats, skunks, foxes, other carnivores
• regard as rabid unless the area is R free or until animalregard as rabid unless the area is R free or until animal
is negative by lab testingis negative by lab testing
• immediate immunization and HRIGimmediate immunization and HRIG
• Bites by squirrels, gerbils, hamsters, G. pigs, rats, mice,Bites by squirrels, gerbils, hamsters, G. pigs, rats, mice,
other rodents, rabbits, hare almost never require anti-Rother rodents, rabbits, hare almost never require anti-R
RxRx
HRIG: human rabies immunoglobulinHRIG: human rabies immunoglobulin
PreventionPrevention

92. VaccinationVaccination
Killed R virus vaccine
 PreexposurePreexposure
 PostexposurePostexposure
 Animal vaccinationAnimal vaccination
15million vaccines are15million vaccines are
pushed worldwidepushed worldwide

93. Who should get the vaccine?Who should get the vaccine?
Pre-exposurePre-exposure
• High-risk people:High-risk people: vets., animal handlers, R lab. workers,vets., animal handlers, R lab. workers,
spelunkers (cave explorer), forestry workers, wildspelunkers (cave explorer), forestry workers, wild
explorers,explorers, travelers in endemic areastravelers in endemic areas
• Also for: Also for: people having frequent contact with R virus,people having frequent contact with R virus,
travelers to endemic areastravelers to endemic areas
• 3 doses: 0-7-21/283 doses: 0-7-21/28thth
d d

94. Benefits of pre-exposure VaxBenefits of pre-exposure Vax
• No need of HRIGNo need of HRIG
• Less post-expo. vax. dosesLess post-expo. vax. doses
• Post exposure Rx might be delayedPost exposure Rx might be delayed
• Protects from inapparent exposures to RProtects from inapparent exposures to R
• For repeated exposure screen for boosterFor repeated exposure screen for booster

95. Post-exposurePost-exposure
• bitten by an animal, or contactbitten by an animal, or contact
• 4 doses: 0-3-7-144 doses: 0-3-7-14thth
daysdays
• They should also get HRIG with first dose vax.They should also get HRIG with first dose vax.
• Pre-vaccinated person get 2 doses: 0-3Pre-vaccinated person get 2 doses: 0-3rdrd
d; no HRIGd; no HRIG
• Should the animal be kept for 10 d?Should the animal be kept for 10 d?

97. Cell culture VaccinesCell culture Vaccines
 Human diploid cell vaccine (HDCV)Human diploid cell vaccine (HDCV)
 Purified chick embryo cell vaccine (PCEC)Purified chick embryo cell vaccine (PCEC)
 Purified Vero cell vaccine (PVRV)Purified Vero cell vaccine (PVRV)
 Purified duck embryo vaccine (PDEV)Purified duck embryo vaccine (PDEV)
Vaccines in BD: Vaccines in BD:
Rabipur (PCEC)Rabipur (PCEC)
Verorab (PVRB)Verorab (PVRB)

98. Future Rabies VaccinesFuture Rabies Vaccines
• Vaccines under development may be safe, potent andVaccines under development may be safe, potent and
cheapercheaper
• DNA vaccinesDNA vaccines, recombinant vaccines, recombinant vaccines
• Plant biotechnology for making AgPlant biotechnology for making Ag
• Neutralizing monoclonal antibodyNeutralizing monoclonal antibody

99. Adverse ReactionsAdverse Reactions
• Less in childrenLess in children
• Adults: local reactions (25%), systemic- (20%)Adults: local reactions (25%), systemic- (20%)
• HA, nausea, AP, aches and dizziness (5-40%)HA, nausea, AP, aches and dizziness (5-40%)
• Very rare:Very rare: illness like GBSillness like GBS
• Immune-complex with boosters: hives, arthralgia, F (6%)Immune-complex with boosters: hives, arthralgia, F (6%)
• Different brands differDifferent brands differ
• Anaphylaxis, if any, occurs within a min- to an hr. withAnaphylaxis, if any, occurs within a min- to an hr. with
dyspnoea, hoarseness, wheeze, throat swelling, hives,dyspnoea, hoarseness, wheeze, throat swelling, hives,
pallor, weakness, tachycardia, or dizzinesspallor, weakness, tachycardia, or dizziness

100. Human Rabies IG (HRIG)Human Rabies IG (HRIG)
• Category iii bite: 20iu/kgCategory iii bite: 20iu/kg
with vax. but different siteswith vax. but different sites
• ½ at the site (infiltrate the½ at the site (infiltrate the
wound); ½ IMwound); ½ IM

101. Basic Care in Animal BitesBasic Care in Animal Bites
• Immediate thorough toileting x15min with soapImmediate thorough toileting x15min with soap
water, detergent, povidone iodine.water, detergent, povidone iodine. Don't suture!Don't suture!
• Categorize the bite:Categorize the bite:
• Post- exposure prophylaxisPost- exposure prophylaxis

103. CategoryCategory -- WHOWHO
• Category I: 1.Category I: 1. touching/feeding suspect animalstouching/feeding suspect animals
2.2. licks on intact skinlicks on intact skin
• Category II: 1.Category II: 1. nibbling of skinnibbling of skin
2.2. scratches/abrasionsscratches/abrasions, but no hge., but no hge.
3.3. licks on broken skinlicks on broken skin
• Category III:Category III: 1 or more1 or more bites/scratches, licks with hge.;bites/scratches, licks with hge.;
contamination of m. membrane with saliva, contactscontamination of m. membrane with saliva, contacts
with batswith bats

104. Category ICategory I
no treatmentno treatment
Category IICategory II
wound disinfection, vaccine onlywound disinfection, vaccine only

105. Category IIICategory III
wound cleansing, HRIG and vaccinewound cleansing, HRIG and vaccine
• Animal observation in our country is not practical:Animal observation in our country is not practical:
frequent bitesfrequent bites
• Delay Rx only ifDelay Rx only if
• Species unlikely to be infectedSpecies unlikely to be infected
• Lab Dx in 48hrLab Dx in 48hr
• Dog >1yr old with current vaccination (observe forDog >1yr old with current vaccination (observe for
10d)10d)

106. Category III bite:Category III bite: bites withbites with
bleedingbleeding

109. • To date only 6 cases survivedTo date only 6 cases survived
• Once clinical, rabies is always fatal, Rx is only supportiveOnce clinical, rabies is always fatal, Rx is only supportive
• Rabies typically ends after 2-10 d (6d)Rabies typically ends after 2-10 d (6d)
No danger of nursing R pts with precautionsNo danger of nursing R pts with precautions
PrognosisPrognosis

110. DDDD
 Other encephalitisOther encephalitis
 Hysteria reaction to animal biteHysteria reaction to animal bite
 GBSGBS
 PoliomyelitisPoliomyelitis
 Allergic encephalomyelitis ( rabies vaccine )Allergic encephalomyelitis ( rabies vaccine )

111. Shots for Dogs Would Save People in DCsShots for Dogs Would Save People in DCs
• Mass vaccination for dogs could eliminate it in humanMass vaccination for dogs could eliminate it in human
• R is rare in HICs (widespread vaccination of dogs)R is rare in HICs (widespread vaccination of dogs)
• Lack of international commitment is among the reasonsLack of international commitment is among the reasons
why rabies in people persistswhy rabies in people persists

112. MCQMCQ
• Most rabies are from bite by rabid dogsMost rabies are from bite by rabid dogs
• Most of rabid-dog bites develop into rabiesMost of rabid-dog bites develop into rabies
• HDCV is at present the best ARVHDCV is at present the best ARV
• Rabies is not transmitted by contaminated corneal graftRabies is not transmitted by contaminated corneal graft
• Rabies is always endemic in the forestRabies is always endemic in the forest

113. MCQMCQ
• Vaccinating pet dogs is essential to control rabiesVaccinating pet dogs is essential to control rabies
• Everyone should be vaccinated against rabiesEveryone should be vaccinated against rabies
• Rabies virus spread to CNS via bloodRabies virus spread to CNS via blood
• It can be transmitted by foodIt can be transmitted by food
• Saliva contains R virus after brain involvementSaliva contains R virus after brain involvement
• Rabies can be eradicatedRabies can be eradicated

115. Next LecNext Lec
Recurrent A. PainRecurrent A. Pain
BronchiolitisBronchiolitis

116. THANK YOU