A challenging presentation of human rabies – experiences from a UK centre

A previously fit and well female presented with headache and pudendal nerve symptoms. We present how her clinical case progressed, ultimately reaching an antemortem diagnosis of human rabies. Background Human rabies is a central nervous system infection caused by several species within the Lyssavirus genus, including rabies virus (RABV). Whilst RABV was eliminated from terrestrial mammals in the UK in 1902, it remains endemic in much of the world leading to sporadic cases in the UK following animal contact abroad. Other Lyssaviruses are maintained in the UK bat population with the potential for human exposure. Case report We describe the case of a 59-year-old female who presented with headache, paraesthesia and spontaneous orgasms following a scratch by a dog in Morocco, 4 months prior. Over the next 10 days, she developed a progressive neuropsychiatric deterioration involving panic attacks, hydrophobia and an ascending flaccid paralysis. Results Cerebrospinal fluid (CSF) examination demonstrated a raised protein with a normal white cell count, opposed to a pleocytosis which is more commonly observed. MRI brain showed bilateral T2/Flair signal changes predominantly involving the white matter bilaterally, which was not characteristic of rabies and observed more commonly in autoinflammatory aetiologies. An antemortem molecular diagnosis of human rabies was made following positive Real Time RT-PCR for RABV on saliva samples. Conclusion This case report highlights an unusual clinical presentation, imaging and CSF changes for human rabies. In addition, we share the challenges of risk assessment and contact tracing in a UK hospital setting. Finally, we discuss how this case may have been prevented, including current barriers to pre and post exposure prophylaxis.