Treatment of Rabies with Hydrophobia
Once a patient develops clinical rabies with hydrophobia, focus exclusively on comfort care and adequate sedation—rabies is not curable at this stage, and aggressive treatment attempts have failed in all but one unvaccinated patient worldwide. 1, 2
Core Management Principles
Primary treatment consists of:
- Comfort care as the minimum standard 1, 2
- Adequate sedation in an appropriate medical facility 1, 2
- Avoidance of stimuli that trigger hydrophobic spasms (loud noises, air currents, sight or sound of running water) 1, 3
Why Sedation is Critical
Patients with furious rabies become extremely agitated during the acute neurologic phase, particularly when exposed to water-related stimuli. 1, 3 The pathognomonic hydrophobia manifests as terror and violent spasms of inspiratory muscles, larynx, and pharynx precipitated by attempts to drink or even by seeing/hearing running water. 3, 4 Heavy sedation prevents this severe agitation and the associated psychological trauma that compounds during periods of lucidity when patients experience isolation and hopelessness from their prognosis. 1
Managing Hydration Needs
For patients with hydrophobia who cannot tolerate oral fluids:
- Administer intravenous fluids for hydration [@general medical knowledge, implied by 1]
- Avoid any oral intake attempts that trigger hydrophobic spasms [@1@, @8@]
- Eliminate visual and auditory water-related stimuli from the patient environment [1, @5@]
The Reality of Prognosis
Rabies carries the highest case fatality rate of any infectious disease. [@4@, @7@] Only 6 documented human survivors exist worldwide, and 5 of these had received pre-symptom vaccination. [@4@, 2,3] Only one patient has ever recovered without prior vaccination. [@1@, @4@, 2]
Vaccination after symptom onset is not recommended and may be detrimental. [@4@]
Experimental Therapies: A Cautionary Note
Medical staff at specialized tertiary care hospitals might consider aggressive experimental therapies (such as the Milwaukee protocol) only in confirmed cases in young healthy persons at early disease stages, but only after in-depth discussions and informed consent. [@1@, @7@] Families must understand:
- High probability of treatment failure [@1@, 2]
- Anticipated substantial expenses 1, 2
- Rare survivors may have severe neurological deficits requiring lengthy rehabilitation 1, 2
The Milwaukee protocol has shown inconsistent outcomes and should not be considered standard care. [@11@]
Infection Control Precautions
Standard precautions are sufficient—rabies patients pose no greater infection risk than patients with common bacterial/viral infections. 1 Healthcare workers should wear gowns, goggles, masks, and gloves, particularly during intubation and suctioning. 1 Postexposure prophylaxis for staff is indicated only if the patient bites someone or if saliva/neural tissue contaminates an open wound or mucous membrane. 1
Prevention Remains the Only Effective Strategy
The combination of wound care, rabies immune globulin, and vaccine is nearly 100% effective when properly administered before symptom onset. [@6@, @13