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Rabies – South Africa (05): (NL) official statement

caoMais um caso paradigmático do que é a RAIVA ! Nunca descurar as medidas de profilaxia Médica e Sanitária em vigor em Portugal é a melhor medida para obstar a estas surpresas LETAIS !
NICD/NHLS statement on human rabies case confirmed KwaZulu Natal,
South Africa
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Rabies has been confirmed in a 29 year old farmer from Underberg,
KwaZulu Natal, South Africa. The patient was admitted to a
Pietermaritzburg, KwaZulu Natal hospital on 2 May 2012 with migratory
pain in his arm and shoulder, unilateral ptosis, fever, confusion, and
progressively hypersalivation and hydrophobia. The patient was already
unwell on 29 Apr 2012. Rabies was considered as a differential
diagnosis when the patient reported contact with a stray dog that died
and with which he had contact 2 months prior to his illness. The
patient provided shelter for the animal, which was initially well but
reportedly developed signs and symptoms consistent with rabies within
a couple of days. The animal was buried on the farm. The patient did
not report any bites or serious injuries from the animal and therefore
did not receive any rabies post exposure prophylaxis at the time.

It is however likely that the patient was in contact with the saliva
of the dog (which may be a source of infection on broken skin or
mucous membranes). Once rabies was suspected in the human patient, the
dog was exhumed and tested positive for rabies. On admission the
patient received rabies immunoglobulin (human origin at 20IU/kg) and
rabies vaccination in the Emergency Department. Once the diagnosis of
rabies was likely, the patient was managed according to a modification
of the Milwaukee protocol (<http://www.chw.org>). Pending laboratory
confirmation of rabies he was treated empirically with acyclovir for
possible herpes infection and quinolones for rickettsial disease.

Laboratory tests for rabies were carried out at the Centre for
Emerging and Zoonotic Diseases, National Institute for Communicable
Diseases of the National Health Laboratory Service (NICD/NHLS) in
Johannesburg. Ante-mortem tests using PCR on multiple samples of
saliva, skin, and cerebrospinal fluid over the course of his illness
were consistently negative. Rabies specific IgG was positive in serum
likely reflecting the recent passive and active immunization of the
patient. Initial serological tests on cerebrospinal fluid were
negative, but rabies specific IgG was detected at low titers on repeat
samples, without an increase in titre over 4 weeks. Extensive testing
for other infectious causes of encephalitis yielded negative results
(including testing for West Nile fever, Rift Valley fever, herpes,
malaria, and enteroviruses).

The patient died on Fri 8 Jun 2012. Life support was discontinued when
a SPECT [single photon emission computed tomography] scanner confirmed
the absence of cerebral blood flow. Rabies was confirmed by a
fluorescent antibody test on a brain biopsy specimen at the
NICD/NHLS.

Underberg is a small rural farming community located approximately 200
km [124 mi] west of Durban. An epizootic of rabies has been ongoing in
KwaZulu Natal Province for about 30 years and animal and human cases
are confirmed from the province annually. The number of human rabies
cases has decreased over the past years following on extensive dog
vaccination campaigns in a number of high-risk areas.

A recent outbreak affecting mainly dogs in the Winterton/Bergville
area of the province has been ongoing since January 2012 and has
claimed the life of one child to date.

The likely origin of the Underberg rabies dog and human cases reported
above is being investigated. Human cases of rabies are confirmed in
South Africa annually. In addition to the case reported here, a
further 5 cases have been confirmed for this year (2012) to date.
These were from KwaZulu Natal (n=2) and Limpopo (n=3) provinces. A
clinical case from the Eastern Cape was reported but could not be
laboratory confirmed. A total of 106 cases of human rabies have been
laboratory confirmed in South Africa from 2005 to date, with the
majority of the cases reported from KwaZulu Natal (n=32), Eastern Cape
(n=30), and Limpopo provinces (n=37).

[From the National Institute for Communicable Diseases of the National
Health Laboratory Service, South Africa
Prof Lucille Blumberg
Dr Jacqueline Weyer
Prof Janusz Paweska
Dr Roger Nattrass, Pietermaritzburg, KZN]

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