Vo1.11,1992
A French Case of Rabies in Europe A 28-year-old man with no previous medical history was admitted to our department with fever and diarrhea after returning from Mexico. On 20 December 1990, the patient and his girlfriend had been bitten by a stray dog found injured by the side of the road between Mexico City and Acapulco. The couple subsequently took no preventive measures. On 5 February 1991, 47 days after the bite, the young man developed fever of 39 °C accompanied by diarrhea and vomiting. He received treatment for these Symptoms, which resulted in transitory clinical improvement. However, on 12 February 1991, he again developed fever of 39 °C. That night his friend noted changes in his behavior, with periods .of apathy accompanied by a fixed stare alternatmg with periods of agitation. His upper extremities would move in an uncoordinated fashion characterized by extension, flexion and internal rotation. Over the next few days the Patient suffered from insomnia, anorexia and an inability to ingest liquids to such a degree that any attempt of oral rehvdration provoked extreme anguish and agitation. He returned to France on 17 February 1991 in a precarious condition with marked asthenia and profound dehydration. On admission, neurologic examination revealed intact mental status but a flaccid paraparesis of the lower extremities with an absence of deep tendon and plantar reflexes. In the upper extremities the motor deficit was less marked and deep tendon reflexes were present. There were no meningeal signs. The patient also exhibited hydrophobic spasms and sialorrhea, He refused oral liquids even though he was severely dehydrated. The physical examination was otherWise unremarkable. Shortly after admission he suffered a generalized seizure which readily resolved with diazepam. Lumbar puncture and cerebral CAT scan were normal. He died shortly thereafter. Diagnosis of rabies was confirmed on brain biopsies by direct tmmunofluorescence assay and virus isolation in the National Reference Center of Rabies (Institut Pasteur). His girlfriend received post-exposure rabies serovaccination. She remains in good health ten months after the contact with a good humoral response to the vaccine. The last human case of rabies in France was diagnosed in 1982 (1) and also followed rabies con-
479
tamination in a foreign tropical country. Indeed, human autochtonous cases have become exceptional in Western Europe: all of the cases between 1977 and 1990 except two (1 in 1979 in Austria and 1 in 1985 in Finland) were.imported (4, 5). This extremely low incidence in Western Europe is attributable to long-standing programs for animal rabies control and human prophylaxis. However, the situation is different in underdeveloped countries, where the number of human cases is approximately 30,000 a year. Domestic animals, mainly dogs, transmit the disease most frequently. Travellers should be informed of the risk of rabies and the available preventive measures (2) that should be taken when visiting countries where rabies is endemic. Pre-exposure rabies vaccination should be recommended to travellers who plan to visit endemic regions where it could be difficult or even impossible to quickly obtain adequate post-exposure treatment
(3).
E Del Giudice 1. E. B e r n a r d 1 P. Rollin 3 E Bertrand 2 E Dellamonica 1 1 Department of Infectious Diseases, Hopital de l'Archet Route de Saint Antoine de Ginesti~re, BP 689, 06012 Nice, France. 2 Department of Emergency, Hopital Saint Roeh, 06000 Nice, France. 3 National Reference Center for Rabies, Pasteur Institute, 25 rue du Docteur Roux, 75724 Paris Cedex 15.
References 1. Berard A: Un cas de rage dans le 'Car. Bulletin Epidemiologique 1982,30. 2. World Heallh Organizalion: Prevention of human rabies in i989, France. Bulletin of the World Health Organization 1991, 66: 12-14. 3. Nieholson KG: Modern vaccines. Rabies. Lancet 1990, i: 1201-1205. 4. Human rabies cases in Europe 1977-1988 and animals responsible for exposure. Rabies Bulletin Europe,
1988, 3: 10. 5. Miiiler WW: Review of reported rabies eases data in Europe to the WHO I:rom 1977 to 1990. Rabies Bulletin Europe 1990, 14: 10-12.
A French Case of Rabies in Europe A 28-year-old man with no previous medical history was admitted to our department with fever and diarrhea after returning from Mexico. On 20 December 1990, the patient and his girlfriend had been bitten by a stray dog found injured by the side of the road between Mexico City and Acapulco. The couple subsequently took no preventive measures. On 5 February 1991, 47 days after the bite, the young man developed fever of 39 °C accompanied by diarrhea and vomiting. He received treatment for these Symptoms, which resulted in transitory clinical improvement. However, on 12 February 1991, he again developed fever of 39 °C. That night his friend noted changes in his behavior, with periods .of apathy accompanied by a fixed stare alternatmg with periods of agitation. His upper extremities would move in an uncoordinated fashion characterized by extension, flexion and internal rotation. Over the next few days the Patient suffered from insomnia, anorexia and an inability to ingest liquids to such a degree that any attempt of oral rehvdration provoked extreme anguish and agitation. He returned to France on 17 February 1991 in a precarious condition with marked asthenia and profound dehydration. On admission, neurologic examination revealed intact mental status but a flaccid paraparesis of the lower extremities with an absence of deep tendon and plantar reflexes. In the upper extremities the motor deficit was less marked and deep tendon reflexes were present. There were no meningeal signs. The patient also exhibited hydrophobic spasms and sialorrhea, He refused oral liquids even though he was severely dehydrated. The physical examination was otherWise unremarkable. Shortly after admission he suffered a generalized seizure which readily resolved with diazepam. Lumbar puncture and cerebral CAT scan were normal. He died shortly thereafter. Diagnosis of rabies was confirmed on brain biopsies by direct tmmunofluorescence assay and virus isolation in the National Reference Center of Rabies (Institut Pasteur). His girlfriend received post-exposure rabies serovaccination. She remains in good health ten months after the contact with a good humoral response to the vaccine. The last human case of rabies in France was diagnosed in 1982 (1) and also followed rabies con-
479
tamination in a foreign tropical country. Indeed, human autochtonous cases have become exceptional in Western Europe: all of the cases between 1977 and 1990 except two (1 in 1979 in Austria and 1 in 1985 in Finland) were.imported (4, 5). This extremely low incidence in Western Europe is attributable to long-standing programs for animal rabies control and human prophylaxis. However, the situation is different in underdeveloped countries, where the number of human cases is approximately 30,000 a year. Domestic animals, mainly dogs, transmit the disease most frequently. Travellers should be informed of the risk of rabies and the available preventive measures (2) that should be taken when visiting countries where rabies is endemic. Pre-exposure rabies vaccination should be recommended to travellers who plan to visit endemic regions where it could be difficult or even impossible to quickly obtain adequate post-exposure treatment
(3).
E Del Giudice 1. E. B e r n a r d 1 P. Rollin 3 E Bertrand 2 E Dellamonica 1 1 Department of Infectious Diseases, Hopital de l'Archet Route de Saint Antoine de Ginesti~re, BP 689, 06012 Nice, France. 2 Department of Emergency, Hopital Saint Roeh, 06000 Nice, France. 3 National Reference Center for Rabies, Pasteur Institute, 25 rue du Docteur Roux, 75724 Paris Cedex 15.
References 1. Berard A: Un cas de rage dans le 'Car. Bulletin Epidemiologique 1982,30. 2. World Heallh Organizalion: Prevention of human rabies in i989, France. Bulletin of the World Health Organization 1991, 66: 12-14. 3. Nieholson KG: Modern vaccines. Rabies. Lancet 1990, i: 1201-1205. 4. Human rabies cases in Europe 1977-1988 and animals responsible for exposure. Rabies Bulletin Europe,
1988, 3: 10. 5. Miiiler WW: Review of reported rabies eases data in Europe to the WHO I:rom 1977 to 1990. Rabies Bulletin Europe 1990, 14: 10-12.
