What is the appropriate management for a 42‑year‑old male pet‑shop owner with suspected rabies encephalitis presenting with three‑day dysphagia, hydrophobia, fluctuating consciousness, agitation, increased muscle tone, brisk reflexes, hypertension and tachycardia after a dog bite four weeks ago?

Management of Suspected Rabies Encephalitis

This patient requires immediate supportive care with intensive monitoring and palliative measures, as rabies encephalitis is universally fatal once clinical symptoms develop, and postexposure prophylaxis is ineffective after disease onset. 1

Immediate Clinical Actions

Confirm the Diagnosis

• Obtain diagnostic specimens immediately to confirm rabies while initiating supportive care 1:
  • Nuchal skin biopsy with immunofluorescent detection of viral antigens (sensitivity 50-94%, specificity approaches 100%) 1
  • Saliva specimens for RT-PCR and viral culture 1
  • CSF for antibody testing (in unvaccinated patients) and RT-PCR 1
  • Serum antibodies (in unvaccinated patients) 1
  • Corneal smear for direct fluorescent antibody testing 2

Provide Intensive Supportive Care

• Transfer to intensive care unit for aggressive supportive management 3, 2, 4:
  • Airway protection and mechanical ventilation as needed for respiratory failure 2
  • Heavy sedation to control agitation and combativeness 2
  • Hemodynamic monitoring and support for autonomic instability (hypertension, tachycardia) 5
  • Seizure management if needed 4
  • Fluid and electrolyte management 3

Implement Infection Control Measures

• Isolate the patient and implement strict contact precautions to prevent exposure of healthcare workers to saliva and other potentially infectious secretions 5
• Document all healthcare personnel and family contacts who may have been exposed to the patient's saliva or neural tissue for postexposure prophylaxis consideration (median 54 contacts per case require prophylaxis) 5

Prognosis and Family Counseling

Rabies encephalitis is invariably fatal once clinical symptoms develop 1, 3, 6. The clinical presentation in this case—hydrophobia, dysphagia, fluctuating consciousness, agitation, and paresthesia at the bite site—represents the classic "furious form" of rabies, which accounts for 80% of cases and progresses rapidly to disorientation, stupor, coma, and death 1, 6.

• No effective treatment exists after symptom onset; postexposure prophylaxis with rabies immunoglobulin and vaccine is only effective before clinical disease develops 1, 6
• Focus care on comfort measures and palliative support rather than aggressive life-prolonging interventions 3, 2
• Provide compassionate counseling to family about the universally fatal prognosis 3, 4

Critical Pitfalls to Avoid

Delayed Diagnosis

• Rabies is frequently underdiagnosed (38% of U.S. cases from 1980-1996 were only diagnosed after death) because clinicians fail to consider it in the differential diagnosis of acute encephalitis 5
• The presence of hydrophobia or aerophobia significantly increases likelihood of antemortem diagnosis (odds ratio 11.0) and should immediately trigger rabies consideration 5
• Lack of definite bite history does not exclude rabies—78% of U.S. cases had no clear exposure history 5

Exposure Risk Assessment

• The dog's death 8 days after biting strongly suggests rabies as the cause, making this a high-probability case 1
• The 4-week incubation period is typical (average 1-3 months, though can range from days to years) 3, 6
• Paresthesia at the bite site one week ago was an early prodromal symptom that should have prompted immediate evaluation 3, 6

Postexposure Prophylaxis Window

• This patient needed immediate postexposure prophylaxis after the dog bite 4 weeks ago—thorough wound cleansing, rabies immunoglobulin, and modern cell culture vaccine 6
• The failure to receive any prophylaxis is the critical error that led to this fatal outcome 2, 4, 6, 5
• Once neurologic symptoms develop, prophylaxis is completely ineffective 1, 6

Healthcare Worker Protection

All medical personnel and family members with potential exposure to the patient's saliva, CSF, or neural tissue require postexposure prophylaxis 5:

• Exposure includes mucous membrane contact, bites, scratches, or contamination of open wounds with infectious material 6, 5
• Administer rabies immunoglobulin and modern cell culture vaccine series to all exposed individuals who have not received preexposure vaccination 6
• Document all contacts systematically as the number can be substantial (range 4-179 per case) 5