I Case Report I RABIES PRESENTING AS ACUTE PSYCHOSIS- REPORT OF TWO CASES -

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I

Case Report

I

RABIES PRESENTING AS

ACUTE

PSYCHOSIS-

REPORT OF TWO CASES

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K.Praveenlal.DPM,MD,Dip,NB~

S.V. Subramanyan. MBBS.

2

N. Pfizer. MBBS.2

N. Krishankutty. M.D.

3

Department of Ps chlatr

,

Medlcal College kkosplta[ Trlvandrum.

1. Assistant Professor

2. Postgraduate student

3. Professor and Head

Abstract

Rabies continues to be a health hazard, especially in developing countries, With a mortality nearing complete and having no specific curative methods. It is more serious than any other infective ill- nesses. Development of the classical symptom

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hydrophobia- leads to easy recognition of this disease. However, nonspecific clinical manifestations are possible. Two cases of rabies manifest- ing as acute psychosis are reported be- cause of the rare presentation.

Introduction

Rabies is a viral infection of mam- mals, primarily carnivores and is usually transmitted by bite (Constantine, 1989)

.

It is a pubic health problem in developing countries (Bogel & Motschwiller, 1986: Steele, 1988).ln India approximately 20,000 people die of this disease every year (Schawbe, 1971 ) and a high proportion of recent human rabies cases were diagnosed even in United states (MMWR,1994).

Early in the disease, constitutional symptoms and signs of local wound infection may be present. During the later stages, a wide array of clinical manifestations may occur, including hydrophobia and aerophobia, which are pathog- nomonic of rabies.

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cases presenting as acute psychosis are reported.

Case 1

Mr. S, 43 years, was brought to Psychiatry outpatient services for the management of fear of enemies and ex- citement of eight hours duration. He had received one day symptomatic treatment for 'mild fever and sore throat' from the general practitioner, prior to the atten- dance to psychiatric department. He had not consumed any food on that day ex- plaining that he was unwell. At midnight, he started making a howling noise and complained that a group of people were trying to strangle him. Because of the fright he wanted his relatives to stay with him. He was excited and howling that whole night. He was evaluvated by the Infectious Diseases Unit and Neurology department a n d was referred to Psychiatry services suspecting Alcohol Related Psychosis.

Apart from the history of suicide in a second degree relative, the family history was not contributory. He had paralytic polio of right upper limb since age four. He was habituated to pan chewing and was an occassional alcohol user. The past history revealed features sugges- tive of delirium almost ten years back.

He was excited

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fearful and non-co operative in the outpatient ssrvices. With a provisional diagnosis of acute

psychosis he was admitted for evalua- tion. In the ward at the time of supervised feeding, hydrophobia and generalised spasm were observed. A history of dog bite 11 0 days back by a familiar stray dog was elicited. patient expired early morn- ing of next day.

Case 2

Smt. V, 34 years reached psychiatry out patients services through medical casuality for the management of fever, decrease of appetite and inomnia of four days duration and crying aloud, running away from home, abusive and assaultive of one day duration. Symptoms were attributed to have started following the failure in her attempt to get a job in the place of her deceased husband. After knowing the rejection of her application, she developed low grade fever, ap- peared sad, communicated less and was sleeples with poor appetite. One day 'prior to consultation, she suddenly ran away from home, crying loudly for no obvious reason. She was irritable and non communicative, but weeping. At- tempts to bring her back home was resisted violently. She refused food and water since that.

Past history revealed her having had one short lasting episode of mental illness with recovery from magical cures, almost 15 years back. A widow for the last five years, she was living with her

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elder sister. Her only son had expired nine years back.

On examination, she was excited, non cooperative and appearing fearful. It was noticed that she was frequently pointing to the fan overhead. On testing, she was found to be phobic to water and air. On further enquiry, it was revealed the she was bitten by a pet dog, which was missing from their place since then. She was diagonsed as a case of rabies and one dose of ARV was given. The full course of treatment could not be given as the relatives shifted her for ayurvedic treatment. Further details could not be collected as she was untraceable.

Discussion

Currently there is no specific treatment for rabies virus infections of humans or animals, having a mortality rate of nearly 100% (Bernard 8 Fish- bein. 1990; Whitley & Modlebrooks

1991 ).

The clinical course of rabies occurs in five stages: incubation period (stage I ) , prodromal period (stage 2), neurological period (stage 3), Coma (stage 4) and recovery (stage 5) (Frenia et al, 1992). The initial presentation of clinical rabies most often is non specific and consists of malaise, fatigue, headache, anorexia and fever, besides pain and paraesthesia at the site of exposure(in 50% of cases). The prodrome

normally lasts for 2 to 10 days and mer- ges with the acute neurologic period with the development of objective signs of central nervous system involvement. The initial neurological signs include hy- peractivity, disorientation, hallucinations, seizures, bizarre behaviour or paralysis. In 50% or more of cases, attempts at drinking during this period are followed by severe spasms of the pharynx and larynx that produce chocking, gagging and fear. These symptoms may be precipitated b y seeing water (hydrophobia) or by blowing air on the face of the patient (aerophobia). During the acute neurological period, the mental status gradually progresses from con- fusion to disorientation, stupor and finally coma and death (Bernard. & Fishbein, 1 990).

Though the text books of Infectious Diseases (Hoeprich& Jordan1 989, Man- dell.et al 1990) mention psychiatric symptoms as prominent presentation, text books of Psychiatry have given only scanty mention(Soloman, 1985 ; Lish- man, 1987). However neuro psychiatric manifestations resulting from antirabies vaccines were reported (Khandelwal et al, 1 985).

The first case decribed in this report had symptoms of stage II and the second case delineated neuropsychiatric symptoms of stage I and stage II

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Diag-

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nosis in the first case was delayed till the accidental observation of classical symptom of hydrophobia. Earlier recognition in the second case was due to suspicion arising from the familiarity of the condition following the first case presented to out patient barely three months back.

In both cases, because of the past history of one episode, psychiatric manifestations could be considered as precipitated by Rabies infection. Lack of awareness about the conditions by patients / medical professionals might have been responsible for considering these cases as probable functional dis- orders.

Unless the acute psychosis presentation of rabies is known, there is a chance non reconginition of the illness. Chances for bite by patient and con- tamination by saliva are high in such presentation. Eventhough rabies by human bite is rare in clinical practice (Dutta et al 1993), chance of virus isola- tion in saliva of affected human subjects is around 59% (Helmick et al, 1987) and there is atleast one anecdotal report of human saliva transmission (Pampoukis, 1 990).

References

1. Bernard KW,Fishbein DB(1990) "Rabies Virus" IniPrinciples & Prac- tice of lnfectious Diseasesl,Eds:

Gerald L, et al, 3 rd edition, pp1291- 1 303.

2. Bogel KG, Motsch WRE (1988) In- cidence of rabies and post exposure treatment in developing countries. Brill world Health org. 64,884-88. 3. Constantine D(1989) "Rabies" In:

Modern Treatise of lnfectious Proces- ses, Eds. Hoeprich PD& Jordan Colin M, 4th edition.Chapter 134.1 155- 1162.

4. Dutta JK, Dutta MK, Das AK (1993) "Questions on Rabies". Jouranl of In- dian Medical Associations. 91 (10) 259-260.

5. Frenia ML, Lafin SM, Barone JA, (1 992)Features and Treatment of rabies Clinical -Pharmacy.ll(l), 37- 41.

6. Hel Mick CG,Tauxe RV,Vernon A A

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(1987) Is there risk to contacts of patients with rabies? Review of Infec- tious Disease 9 5 1 1-51 8.

7. Hoeprich PD,Jordan Co1in.M. (1989) lnfectious Disease

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A Modern Treatise to lnfectious Processes. 4th edition. Chapter 134. 115-1162. 8. Khandelwal SK, Murthy RS, Varma VK

(1 985) Neuro Psychiatric complica- tions of anti

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rabies vaccine. Review with case reports. Indian Journal of Psychiatry. 23 (2): 163-1 66.

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Second editon. Blackwell scientific publication. Oxford, London,

10. Mandell GL, Gordon DR, Bennet John E (1 990)Principles & Practice of Infectious Diseases 3rd edition. pp 1291 -1 303.

11 .MMWR (1 994)Human Rabies-Miami 1994 Oct. 28,43 (42): 773- 775. 12. Pampoukis PS(1990)Rabies by

human bite Ann. Int. Poster (Paries) 14,11.

13. Schwabe CW (1 970) Report of 1 st W.H.0 seminar on veterinary public helath, India WHO, Geneva. 16. 14.Steele JH(1988)Rabies in Americans

and remarks on global aspects Review of lnfectious Diseases 10 (SUPPI 4) 585- 59.

15. Whiteley & Middle Brooks (1991): Rabies. 1n:lnfections of central nervous system. Eds Scheld WM et al , , Raven Press, NewYork.ppl27

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Reprint Request Dr.Praveen Lal , Professor of Psychiatry,