Sir, Rabies is an acute, progressive encephalitic disease caused by the rabies virus, a neurotropic RNA virus in the Lyssavirus genus of the Rhabdoviridae family. Transmission to humans occurs predominantly through bites from infected canines’ saliva.1 Despite being vaccine-preventable, rabies still claims more than 59,000 lives annually worldwide – predominantly in Asia and Africa – with India alone accounting for approximately 36% of global rabies deaths.2 Herein, we report two cases of rabies encephalitis with delayed onset and fulminant deterioration, underscoring the diagnostic challenges and the critical importance of timely prophylaxis in endemic regions. CASE SUMMARY A 58-year-old male with no known comorbidities presented to the emergency department with a 3-day history of agitation, hypersalivation, aerophobia and hydrophobia. The family reported worsening behavioural disturbance, restlessness and refusal to drink fluids. Two years earlier, he sustained an unprovoked bite to the lower limb from an unvaccinated stray dog known to have bitten multiple individuals. The patient did not receive post-exposure prophylaxis (PEP). On examination, he was alert but markedly agitated, responding aggressively to air and water stimuli. Vital signs showed a heart rate of 138 bpm and stable blood pressure. Neurological examination revealed no focal deficits; however, he exhibited spontaneous limb movements and intermittent decerebrate posturing. Given rapid neurological deterioration with agitation and compromised airway protective reflexes, the patient was intubated for airway protection and managed with supportive critical care, including sedation, mechanical ventilation and haemodynamic monitoring. Despite aggressive management, the patient succumbed to his illness within 5 h of presentation. Another 48-year-old male, previously neurologically intact, presented to our emergency department with intense fear of liquids, excessive salivation and episodic agitation over 5 days. He refused all oral intake and developed signs of autonomic dysregulation, including tachycardia and profuse sweating. His history included two previous dog bites: one in early childhood and another a year earlier, both from unvaccinated dogs. No medical care or PEP was administered in either case. On examination, the patient was conscious but disoriented, with hydrophobia and aerophobia. He exhibited involuntary grimacing and respiratory spasms when presented with water. Vitals included heart rate: 147 bpm, blood pressure: 110/70 mmHg and respiratory rate: 38/min. Neurological examination showed hyperreflexia without focal deficits. Supportive treatment, including intubation, hydration and sedation, was initiated. However, he succumbed to his illness within 24 h of admission. A timeline of events is shown in Figure 1, which compares both cases.Figure 1: Timeline of events in both patients. PEP: Post-exposure prophylaxis, ED: Emergency department, ICU: Intensive care unitDISCUSSION Both patients exhibited the classic features of furious rabies: hydrophobia, aerophobia, hypersalivation, agitation and autonomic instability. These hallmark features are diagnostic in endemic areas, especially when paired with a suggestive bite history, even if remote.3 After inoculation, the virus replicates locally in muscle tissue before ascending the peripheral nervous system via retrograde axonal transport to the central nervous system (CNS), where it causes fatal encephalitis.3 The incubation period is highly variable – typically 1–3 months – but may extend to years, depending on host immunity, bite severity and proximity to the CNS (as in our cases).4 Rabies diagnosis is primarily clinical, especially in resource-limited settings. Once symptoms appear, rabies is nearly universally fatal despite intensive supportive care.5 These two fatal cases of rabies encephalitis, presenting after unusually long incubation periods, exemplify the silent and unpredictable course of rabies in endemic areas. Clinicians must remain vigilant for rabies in any encephalitic presentation, especially when unexplained autonomic symptoms and phobic spasms are present. These cases also highlight public health system gaps, including inadequate community education about the importance of PEP, poor follow-up of reported animal bites and limited access to vaccines in peripheral regions. Authors’ contributions NS: Concept, design, manuscript preparation, manuscript editing and manuscript review. BM: Data acquisition, data analysis, literature search, manuscript preparation, manuscript editing and manuscript review. UAM: Manuscript preparation, manuscript editing and manuscript review.. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.
Sriramula et al. (Fri,) studied this question.