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

Mumps Mumps RubellaRubellaRabiesRabies

Mumps Mumps RubellaRubellaRabiesRabies

Dr Mohammad Nurul Huq Dr Mohammad Nurul Huq

MUMPSMUMPS

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

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/y Incidence: 100–1k/100k/y Anyone non-immune can get itAnyone non-immune can get it Before vax., it was common in Before 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 nm variable shape. Size: 120–450 nm

TransmissionTransmissionTransmissionTransmission

• Worldwide. Worldwide. HumansHumans are the are 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• IP IP ~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

CL. FEATURESCL. FEATURESCL. FEATURESCL. FEATURES

• A multi-system viremiaA multi-system viremia• 50%50% subclinical subclinical 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 of tiredness, 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

Mostly Mostly mild mild in children,in children, more severe in adults with more more severe in adults with more complications complications

PPeak: eak: aged 5–9yaged 5–9y In In >50%: CSF pleocytosis >50%: CSF pleocytosis but <10% have CNS symptomsbut <10% have CNS symptoms Encephalitis and permanent neurological sequelae rare Encephalitis and permanent neurological sequelae rare 11stst TM of preg: TM of preg: abortion abortion Crosses placenta but no cong. malformationCrosses placenta but no cong. malformation

CL. FEATURES ..CL. FEATURES ..CL. FEATURES ..CL. FEATURES ..

Parotitis. Edematous swelling extends below the angle of mandibleParotitis. Edematous swelling extends below the angle of mandible

Normal

Full recess

Parotitis with Parotitis with transient neck transient neck and presternal and presternal edema and edema and erythemaerythema

Other C/of ParotitisOther C/of ParotitisOther 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

DIAGNOSISDIAGNOSISDIAGNOSISDIAGNOSIS

• Mainly clinical. Mainly clinical. Salivary amylase Salivary amylase • Virus in saliva, throat, urine, CSFVirus in saliva, throat, urine, CSF• Specific IgM, PCRSpecific IgM, PCR• Significant Significant of sp. IgG titers between acute and of sp. IgG titers between acute and

convalescent samplesconvalescent samples

ComplicationsComplicationsComplicationsComplications

• 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• Endocardial Endocardial

fibroelastosisfibroelastosis

The highest risk is in males 15-29yThe highest risk is in males 15-29y

SupportiveSupportive• Analgesic, antipyretic, hot moist compressAnalgesic, antipyretic, hot moist compress

OUTBREAK CONTROLOUTBREAK CONTROL• Exclude affected students for Exclude 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: no Immunization during IP: no risk risk

TREATMENTTREATMENTTREATMENTTREATMENT

ISOLATIONISOLATIONISOLATIONISOLATION

Droplet precautions until Droplet precautions until 5d 5d 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 tissue Stay home for 5d. Cover mouth and nose with a tissue

when cough/sneeze; cough/sneeze into your upper sleeve when 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

MUMPS VACCINEMUMPS VACCINEMUMPS 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 later dose at least 1mo-1y later• Immunize Immunize before before puberty. puberty. No mumps vax. after ≥50yNo mumps vax. after ≥50y

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. If None 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 those Children with egg allergy can be immunized but not those

with anaphylaxis to eggwith anaphylaxis to egg• Immunocompromised (HIV, cancer, steroids)Immunocompromised (HIV, cancer, steroids)

PregnancyPregnancy

• NoNo conception for 4w. Avoid in pregnancy conception for 4w. Avoid in pregnancy• Vax. virus Vax. 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 ImmunityAvoid Avoid in Ca, steroid Rx., chemo-, radiation etc.in Ca, steroid Rx., chemo-, radiation etc.

Exception is HIVException is HIVRisk of M in altered immunity is Risk of M in altered immunity is by vaccinating close by vaccinating close

contactscontacts

Immune people do not transmit M vax. virusImmune people do not transmit M vax. virus

• IVIg IVIg (Kawasaki D, GBS)(Kawasaki D, GBS) can inhibit response. can inhibit response. Push Push 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 >20 1 mo after stopping steroids (2 mg/kg/d or >20

mg/day for mg/day for ≥≥14 d)14 d)• Immunosuppression: wait 3 mo after stopping Immunosuppression: wait 3 mo after stopping

Ig AdministrationIg Administration

RUBELLARUBELLA

EPIDEMIOLOGYEPIDEMIOLOGYEPIDEMIOLOGYEPIDEMIOLOGY

• 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

CL. MANIFESTATIONSCL. MANIFESTATIONSCL. MANIFESTATIONSCL. MANIFESTATIONS

Postnatal RubellaPostnatal Rubella

• MildMild• Generalized Generalized MPR, GLAP MPR, 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

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

Distribution is Distribution is similar to that of similar to that of measles but less measles but less

intenseintense

"blueberry muffin"

Newborn with CRSNewborn with CRS

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

CRS triadCRS triad

• Ear: Ear: sensorineural deafness sensorineural 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

Commonest CRS anomaliesCommonest CRS anomalies

• Retinopathy, cataract, glaucomaRetinopathy, cataract, glaucoma• PDAPDA• DeafnessDeafness• Behavioral disorders, MR, meningoencephalitis Behavioral disorders, MR, meningoencephalitis

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

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

CRS: PDA and bone changes

Longitudinal sclerotic striae (celery Longitudinal sclerotic striae (celery stalk) at metaphyses which are stalk) at metaphyses which are irregular with dense bands irregular 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

Radiolucent long bone changes in metaphyses in CRS

microphthalmos and cataract

CRS pneumonia

CRS: microcephaly

DIAGNOSISDIAGNOSISDIAGNOSISDIAGNOSIS

• Virus from nose, blood, urine, CSF, TSVirus from nose, blood, urine, CSF, TS• Sp. IgM may be Sp. IgM may be falsefalse--positivepositive; ; confirm by confirm by

stable/rising RIgG over several mo. (4-fold stable/rising RIgG over several mo. (4-fold ) ) • Dx of Dx of CRS CRS after >1y of age is difficult: serology is after >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

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 later test 3w later• If negative, do 3If negative, do 3rdrd test 3w after 2 test 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

Treatment:Treatment: SupportiveSupportive

DD (post natal rubella)DD (post natal rubella)

• MeaslesMeasles• AdenovirusAdenovirus• EnterovirusEnterovirus• Drug rashDrug rash• Scarlet feverScarlet fever• DengueDengue• Typhoid/typhusTyphoid/typhus

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

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:

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 is Immunizing children whose contacts are pregnant is

not a risknot a risk• Immunized people may shed vax. virus for 28d, but no Immunized people may shed vax. virus for 28d, but no

evidence of transmissionevidence of transmission

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; more in Arthralgia 25% and reactive arthritis 10% 1-3w later; more in

femalesfemales• Rash 5%Rash 5%• ThrombocytopeniaThrombocytopenia

IVIGIVIG• mmay interfere immune response. R. vax. may be ay interfere immune response. R. vax. may be

given to women along with anti-Rh (D) or blood given to women along with anti-Rh (D) or blood products, but tested products, but tested ≥≥8 w later to see 8 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 contactsCorticosteroidsCorticosteroids• 1 month after HD steroids for 1 month after HD steroids for ≥≥14 days14 days

FDA: Indications of IVIgFDA: Indications of IVIgFDA: 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 ABO Kidney transplant with a high Ab recipient or with an ABO

incompatible donorincompatible donor

Reactive ArthritisReactive Arthritis

autoimmune A. in response to an infx. in non-articular part of autoimmune A. in response to an infx. in non-articular part of the body, GU or GIT the body, GU or GIT (cross-reactivity)(cross-reactivity) usually by a bacterium usually by a bacterium ("trigger”) which is cured (commonly salmonella, shigella, ("trigger”) which is cured (commonly salmonella, shigella, campylobacter, campylobacter, C. trachomatis C. trachomatis or or 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

• RA often is coupled with RA often is coupled with Reiter's Syn. ofReiter's Syn. of arthritis, arthritis, conjunctivitis/uveitis, and urethritis in men or cervicitis in conjunctivitis/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

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

Rabies

(Rhabdovirus)

Rabies

(Rhabdovirus)Rabhas means Frenzy

World Rabies Day (Sept. 28)World Rabies Day (Sept. 28)

• … … to reduce to reduce the suffering the suffering from rabiesfrom rabies

At the end of session you will learnAt the end of session you will learn

• Rabies: an invariably fatal Rabies: an invariably fatal encephalitisencephalitis. Only . Only mammals affected. mammals affected. Always endemic in the wildAlways endemic in the wild

• Virus Virus descends descends 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 mortality in mortality• 100% preventable100% preventable

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

What is Rabies?What is Rabies?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

Rhabdo/lyssa virusesRhabdo/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 (6000c x5 min)c x5 min)

Lyssa means rageLyssa means rage

Fixed and Street VirusFixed and Street VirusFixed and Street VirusFixed and Street Virus

• Fixed virus Fixed virus (lab virus)(lab virus): : Rabies virus after serial passage Rabies 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

EpidemiologyEpidemiologyEpidemiologyEpidemiology

• Primary reservoirs: Primary reservoirs: wild mammalswild mammals• Only Only mammals mammals affected; except affected; except mice !mice !• ManMan, dogs, raccoons, skunks, foxes, bats, cats, cattle , dogs, raccoons, skunks, foxes, bats, cats, cattle

commonlycommonly affected affected• It is endemic in many countries except Australia, Malaysia, It is endemic in many countries except Australia, Malaysia,

Japan, Bhutan, NepalJapan, Bhutan, Nepal

Distribution of rabies reservoirs Distribution of rabies reservoirs

RaccoonsRaccoons

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

• Bites, abrasionsBites, abrasions• Scratches, Scratches, aerosol (bats)aerosol (bats)• Mucosal exposureMucosal exposure

• RarelyRarely• eating infected meateating infected meat• corneal transplantationcorneal transplantation

TransmissionTransmissionTransmissionTransmission

PathogenesisPathogenesis

• IP: 9-90d IP: 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

Pathogenesis ..Pathogenesis ..Pathogenesis ..Pathogenesis ..

• RV replicates in muscles: enters nerves and ascends to RV 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

Pathogenesis ..Pathogenesis ..

Live virus Live virus skin: mucosa: muscle skin: mucosa: muscle

Peripheral nervePeripheral nerve

CNS (gray matter)CNS (gray matter)

Salivary, eyes, breast, kidneysSalivary, eyes, breast, kidneys

moves centripetally

moves centrifugally

HistopathologyHistopathology

• EncephalomyelitisEncephalomyelitis• Perivascular inflammatory cellsPerivascular inflammatory cells• Neuronal cytoplasmic inclusion (Negri bodies) esp. in Neuronal cytoplasmic inclusion (Negri bodies) esp. in

pyramidal cellspyramidal cells

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/ paresthesia Discomfort/ paresthesia at bite site (50%)at bite site (50%)• BBizarre behaviorizarre behavior

On progression: On progression: neuro-symptoms:neuro-symptoms:

Neuro-symptoms: Neuro-symptoms: bbroad categoryroad category Neuro-symptoms: Neuro-symptoms: bbroad categoryroad category

• Furious rabies (80%)Furious rabies (80%)• Dumb or paralytic rabies Dumb or paralytic rabies

(GBS) 20%(GBS) 20%

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

Dumb/paralytic rabiesDumb/paralytic rabies

• S/of partial/full paralysisS/of partial/full paralysis usually begins in the limbs and usually begins in the limbs and spreads all overspreads all over

• Hydrophobia is Hydrophobia is unusualunusual• Progress to coma and death (heart or lung failure)Progress to coma and death (heart or lung failure)

A rabid dog displaying A rabid dog displaying the classic form of the classic form of paralytic R, cranial-paralytic R, cranial-nerve deficits and nerve deficits and hypersalivationhypersalivation

Routine rabies tests:Routine rabies tests:• Direct fluorescent antibody test (dFA:) (only post Direct fluorescent antibody test (dFA:) (only post

mortem)mortem)• Histopathology: Histopathology: Negri Negri bodies. Immunohistochemistry bodies. 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. trauma Save a pt. from unnecessary physical and psycho. trauma

if the animal is not rabidif the animal is not rabid

Diagnosis in AnimalsDiagnosis in AnimalsDiagnosis in AnimalsDiagnosis in Animals

dFAdFA detects RVdetects RV

• Ideal tissue is nerve (brain)Ideal tissue is nerve (brain)• Fl. anti-rabies Ab incubated with brain tissue fixes RV; seen Fl. 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

DFA negativeDFA negative

DFA positiveDFA positive

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

Rabies Dx in Humans Rabies Dx in Humans

• No test available before cl. diseaseNo test available before cl. disease• Confirmed pre- and post mortem by detecting RV, viral Ag in Confirmed 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

Prevention Prevention Prevention Prevention

• 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 animals No 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

• 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 animal is regard as rabid unless the area is R free or until animal is

negative by lab testingnegative 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-R Rxother rodents, rabbits, hare almost never require anti-R Rx

HRIG: human rabies immunoglobulinHRIG: human rabies immunoglobulin

Prevention Prevention Prevention Prevention

VaccinationVaccination

Killed R virus vaccine PreexposurePreexposure PostexposurePostexposure Animal vaccinationAnimal vaccination

15million vaccines are 15million vaccines are pushed worldwidepushed worldwide

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, wild spelunkers (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

Benefits of pre-exposure VaxBenefits of pre-exposure Vax 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

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 days days• 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 HRIG d; no HRIG• Should the animal be kept for 10 d?Should the animal be kept for 10 d?

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)

Future Rabies VaccinesFuture Rabies VaccinesFuture Rabies VaccinesFuture Rabies Vaccines

• Vaccines under development may be safe, potent and Vaccines 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

Adverse ReactionsAdverse ReactionsAdverse 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. with Anaphylaxis, 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

Human Rabies IG (HRIG)Human Rabies IG (HRIG)Human Rabies IG (HRIG)Human Rabies IG (HRIG)

• Category iii bite: 20iu/kg Category iii bite: 20iu/kg with vax. but different siteswith vax. but different sites

• ½ at the site (infiltrate the ½ at the site (infiltrate the wound); ½ IMwound); ½ IM

Basic Care in Animal BitesBasic Care in Animal BitesBasic Care in Animal BitesBasic Care in Animal Bites

• Immediate thorough toileting x15min with soap Immediate 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 prophylaxis Post- exposure prophylaxis

CategoryCategory - - WHOWHOCategoryCategory - - 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 skin licks on broken skin• Category III: Category III: 1 or more 1 or more bites/scratches, licks with hge.; bites/scratches, licks with hge.;

contamination of m. membrane with saliva, contacts contamination of m. membrane with saliva, contacts with batswith bats

Category ICategory Ino treatmentno treatment

Category IICategory IIwound disinfection, vaccine onlywound disinfection, vaccine only

Category IIICategory III

wound cleansing, HRIG and vaccinewound cleansing, HRIG and vaccine

• Animal observation in our country is not practical: frequent Animal observation in our country is not practical: frequent bitesbites

• 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 for Dog >1yr old with current vaccination (observe for

10d)10d)

Category III bite: Category III bite: bites with bites with bleedingbleeding

• 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

PrognosisPrognosisPrognosisPrognosis

DDDD

Other encephalitis Other encephalitis Hysteria reaction to animal biteHysteria reaction to animal bite GBS GBS PoliomyelitisPoliomyelitis Allergic encephalomyelitis ( rabies vaccine )Allergic encephalomyelitis ( rabies vaccine )

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 reasons Lack of international commitment is among the reasons

why rabies in people persistswhy rabies in people persists

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

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

Next LecNext Lec

Recurrent A. Pain Recurrent A. Pain BronchiolitisBronchiolitis

Next LecNext Lec

Recurrent A. Pain Recurrent A. Pain BronchiolitisBronchiolitis

THANK YOU