What is the appropriate management plan for a 42‑year‑old man with classic furious rabies encephalitis presenting four weeks after a dog bite without prior post‑exposure prophylaxis?

Management of Furious Rabies Encephalitis

Once clinical rabies encephalitis has developed, there is no effective treatment and the disease is invariably fatal—management is purely supportive and palliative. 1

Critical Understanding of Disease Stage

• Postexposure prophylaxis (rabies immunoglobulin and vaccine) is completely ineffective after the onset of clinical disease. 1
• This patient presenting four weeks after exposure with classic furious rabies (agitation, hydrophobia, bizarre behavior, delirium) has progressed beyond the point where any rabies-specific intervention can alter the outcome. 1
• The administration of postexposure prophylaxis to a clinically rabid human patient has demonstrated consistent ineffectiveness. 1

Immediate Diagnostic Confirmation

While management proceeds, confirm the diagnosis through:

• Serum antibodies in this unvaccinated patient 1
• RT-PCR of saliva specimens (most practical antemortem test) 1, 2, 3
• Immunofluorescent detection of viral antigens in nuchal skin biopsy 1, 2, 3
• Corneal smear for rabies virus antigen by direct fluorescent antibody test 2, 3
• CSF antibodies and RT-PCR of CSF specimens 1, 3

Supportive Care Approach

Intensive supportive care with heavy sedation and mechanical ventilation is the only management option, though survival is extraordinarily rare. 2, 4, 3

Specific Management Components:

• Heavy sedation to control agitation, anxiety, and autonomic hyperactivity 2, 4
• Mechanical ventilation for progressive respiratory failure 2, 4, 3
• Cardiac monitoring for arrhythmias including complete heart block, which is common 4, 3
• Management of autonomic dysfunction including hypersalivation, fever, and cardiovascular instability 2, 3

Milwaukee Protocol Considerations:

• The Milwaukee Protocol (therapeutic coma with antiviral agents) has been attempted in some cases but has shown extremely limited success, particularly for canine-derived rabies strains. 3
• Post-mortem analysis of cases managed with the Milwaukee Protocol shows complete absence of neutralizing antibody and widespread viral distribution despite intensive care. 3
• The role of the Milwaukee Protocol in improving outcomes for canine-derived rabies remains theoretical. 3

Infection Control and Public Health Measures

• Strict isolation precautions to protect healthcare workers from exposure to saliva and other potentially infectious body fluids 2
• Immediate notification of public health authorities for contact tracing and potential postexposure prophylaxis of exposed individuals 2
• Investigation of the source animal and other potential exposures in the community 2

Prognosis and Family Counseling

• Death typically occurs within 7-22 days after symptom onset despite intensive medical treatment. 2, 4, 3
• Once cerebral activity ceases, supportive care should transition to comfort measures only. 4
• This case underscores the absolute necessity of immediate postexposure prophylaxis after any potential rabies exposure—vaccination must be carried out immediately after exposure since once encephalitis develops, a fatal outcome cannot be prevented even with intensive medical treatment. 4

Critical Pitfall to Emphasize

The fundamental failure here was the refusal of postexposure prophylaxis after the dog bite five months ago. 2 This case highlights the critical importance of public education about rabies transmission and the absolute necessity of postexposure prophylaxis, which is nearly 100% effective when administered before symptom onset but completely ineffective once clinical disease develops. 1, 2, 5