In September 2004, animal-loving Wisconsin teenager Jeanna Giese picked up a bat trapped inside her church and took it outside. As she tried to set it free, the bat sank its teeth into her left index finger for an instant before she shook it loose.
Explore this issue:September 2007
Back at home, her mother rinsed the tiny wound with hydrogen peroxide and thought no more about it. A month later, the girl, a star student and athlete, developed fatigue, double vision from bilateral sixth nerve palsies, and paresthesias in her left arm. She deteriorated rapidly over the next few days, with high fever, ataxia, confusion, tremor, drooling, and spasm with swallowing, and was intubated for airway protection. Rabies antibody was found in her spinal fluid and serum.
The Fond du Lac girl’s doctors at Children’s Hospital of Wisconsin (Milwaukee) offered the family a dismal choice. She could receive hospice care for the gruesome and invariably fatal consequences of rabies in unvaccinated patients. Or, the doctors could embark on experimental treatment, with no guarantee she would have any meaningful neurological function or quality of life should she survive.
Parents Chose Treatment
On the basis of data indicating rabies patients are capable of clearing the virus, but die largely of secondary complications (e.g., autonomic dysfunction and excitatory neurotoxicity), the team administered massive doses of ketamine, midazolam, and phenobarbital, the antivirals ribavirin and amantadine, and supplementation with coenzyme Q to counter the possible mitochondrial toxicity of ribavirin. Ketamine blocks the neuroexcitatory NMDA receptor, possibly a receptor for rabies virus.
After a stormy, four-week intensive-care course characterized by autonomic instability and other complications, Giese was extubated and went home on New Year’s Day 2005. She made a remarkable recovery, eventually returning to school full time— although she was unable to participate in athletics. At 17, she has been accepted to college to study biology starting this fall.1-3
While the Wisconsin protocol has achieved the previously impossible, it is not yet a surefire cure for rabies. Two U.S. children treated last year with the Wisconsin protocol and meticulous supportive care died—one with cerebral edema, the other with cerebral and cerebellar herniation.4 Additional clinical experience and further tinkering with the protocol are likely required to optimize outcomes.
What To Know
While rabies is rare is the U.S., it retains a disproportionate importance because of its historic 100% fatality rate. Hospitalists should know this about rabies: