Case presentation
The patient was a 13-year-old boy from Ali Ala village of Esfarayen city
in North Khorasan province, with headache and akathisia. The patient had
complained of a headache to the family physician and received
symptomatic treatment and was referred to the hospital due to the
aggravation of the headache and changes in morals. In reported history,
it was found that about 2 months ago, the child suddenly had a scratch
on the head by a fox while sleeping. The scratch was accompanied by
bleeding but they did not go to any of the health centers. In other
records, his father was addicted to methamphetamine, but he denied
taking the drug. They did not mention the consumption of canned or
vegetarian foods and there were no similar symptoms in the family. Other
prodromal symptoms such as coryza, fever, and cough were absent.
Upon arrival at the hospital; the child was alert and extremely
restless. He answered the questions appropriately but did not cooperate
with the check-up doctor. The patient’s vital signs including blood
pressure (130/100), heart rate (170 per minute), respiratory rate (25
per minute), central temperature (37 ° C) were recorded. His eyes were
proptosis and the pupils were mydriatic. the scratch was seen on his
scalp but had healed and had no signs of infection. There was a slight
runny of his mouth that became more frequent when was talking. He had
photophobia and did not enter the check-up room, which was brighter. He
also had hydrophobicity, so he became agitated to receive the patient’s
serum or glass of water. His respiratory sounds were normal, but in his
cardiac auscultation systolic murmurs of 3.6 were heard on the left side
of the chest. The cranial nerves examination was normal. he had a gag
reflex, and the tonicity of his limbs was 5.5 at the time of admission.
In the initial tests of him, leukocytosis (WBC = 19700) was evident
along with lymphopenia (lymph: 7%). Other blood types were normal. In
the blood gas test, PH: 7.45, PCO2: 30, HCO3: 21, and CPK: 77 were
reported.
During the hospitalization, sedative treatment was started to control
the patient’s agitation. Urine toxicology for amphetamines was evaluated
for possible substance abuse. On suspicion of rabies, the city health
center was informed and vaccine and rabies serum was injected. Ribavirin
was also administered to the patient and he was monitored continuously
for clinical symptoms and level of consciousness. To investigate other
causes of encephalitis, a Lumbar puncture was performed.
About 14 hours after hospitalization, the gag reflex completely
disappeared and dysarthria occurred. On other neurological examinations,
the patient developed flaccid paralysis with generalized areflexia. His
mouth watering had increased dramatically, but the child was still alert
according to the clinical condition, he was intubated and connected to a
respirator and died about 24 hours after the patient’s visit.
Three saliva samples and skin biopsies were prepared from hair follicles
in the neck area and brain tissue biopsies were performed after the
patient’s death to evaluate rabies, which was sent to the Pasteur
Institute of Iran.
The submitted tests were negative for amphetamines. Polymerase chain
reaction (PCR) testing of cerebrospinal fluid (CSF) was reported to be
positive for rabies as well as COVID-19. In the samples sent to the
Pasteur Institute of Iran, the diagnosis of rabies was confirmed by
Negri bodies.