A Rare Case of Dumb Rabies Mimicking Guillain Barre Syndrome

Abstract

Introduction: Rabies is a zoonotic disease that spread through animal bites (dog bites in tropical countries). Rabies can be presented in two forms: (i) Encephalitic
and (ii) Paralytic rabies. Encephalitic (Furious) rabies is seen in 80% of cases whereas Paralytic (dumb) rabies in 20% of cases. Encephalitic rabies presents with
cardinal symptoms like hydrophobia and aerophobia whereas paralytic rabies presents with acute flaccid paralysis resembling Guillain barre syndrome (GBS).
Multiorgan dysfunction occurs in both forms but occurs late in paralytic rabies.
Case representation: A 37-year-old male presented with complaints of fever, weakness of both upper and lower limb weakness, neck drops, and hoarseness of voice
from 4 days with a history of category III dog bite 30 days back for which he took tetanus toxoid, rabies immunoglobulins and took 5 doses of ARV (anti-rabies
vaccine) as prophylaxis. There was no history of hydrophobia or aerophobia. At the time of presentation, his vitals were stable. On examination there was bilateral
lower motor facial nerve palsy along with bulbar palsy, hypotonia in both upper and lower limbs, reduced power in all limbs, absent deep tendon reflexes, and plantar
reflex showing mute response on both sides. Routine blood tests showed neutrophilic leucocytosis and moderate hyponatremia with serum sodium - 126 meq/L.
Nerve conduction studies were inconclusive. MRI brain showed bilateral thalamic hyperintensities. CSF analysis is unremarkable. A provisional diagnosis of GBS
was made and IVIG with the dose of 2 g/kg over 5 days was started. Later in the hospital, he was intubated in view of respiratory distress and tachypnea. The patient
developed generalized tonic colonic seizures later in the course of the hospital. The patient’s GCS gradually deteriorated and went into cardiac arrest. CPR was done
and resuscitated. After two days, the patient went into cardiac arrest and could not be revived despite resuscitative efforts. The patient succumbed on the eighth day
of admission.
Conclusion: Paralytic rabies is an uncommon presentation of rabies and is more common in rabid bat bites observed in Western countries. It is uncommon in dog
bite which is rampant in Asian countries. Moreover, cases of dumb rabies presenting as acute flaccid paralysis resembling GBS pose diagnostic challenges. Hence, a
history of dog bites and post-exposure prophylaxis should be sought [2]. The presence of fever and constitutional symptoms should lead to a search for an alternate
diagnosis [3]. In Western countries, even the absence of a bite should raise the suspicion of rabies. Paralytic rabies is a common presentation in patients presenting
with adequate post-exposure prophylaxis. Even though rare, vaccine-induced GBS should be taken into consideration for diagnosis [2].