Discussion
We presented a case of a 13-year-old boy diagnosed with rabies and covid-19 infection.
The Covid-19 pandemic has made public health departments necessarily shift their focus and resources to enforcing stay-at-home orders and stepping up emergency preparedness efforts. Reducing the vaccination coverage of dogs as well as reducing monitoring, which leads to an increase in the lifespan of infected dogs, can lead to a sharp increase in rabies in dogs and thus the risk of rabies in humans (6).
The rabies virus belongs to the Rhabdoviridae family and lyssavirus genus. the virus causes acute disease of the central nervous system is specific to domestic and wild carnivores, and humans and other warm-blooded vertebrates are infected accidentally, often through bites. The fatality rate of the disease is so high that after the appearance of clinical symptoms in both humans and animals, treatment is not possible and death will be inevitable (7).
Rabies in humans is divided into four periods. The incubation period usually lasts 15 days to 3 months (average 1-2 months) (8). The present patient was also bitten by a fox on the head about 2 months before the onset of symptoms. The most dangerous areas are the hands, neck, face, and head, which lead to shorter incubations due to the reduction in the length of neurons and the increase in their number. RABV can generally persist in muscle for a long time, which may increase the chances of post-exposure treatment and clearance of RABV by the host immune system (9).
The second period is the onset of early signs in the patient. The duration is 1-4 days, and at the end of the incubation period, the rabies virus penetrates the junction of nerves and muscles or the ends of superficial motor nerves and spread to the spinal cord of the central nervous system. The virus reaches the spinal cord 2-8 mm per day. Early nonspecific symptoms of rabies include fever and chills, fatigue, headache, muscle weakness, pain, bloating, difficulty swallowing, nausea, and vomiting. In the reported patient, headache and agitation were the primary cause.
The third stage, acute neuropathy, beginning with dysfunction of the central nervous system occurs in two forms: furious and paralytic rabies (2). Furious rabies symptoms include aimless running and paddling, irritability and agitation, hallucinations, anxiety, and excitement, increased salivation, and difficulty swallowing. hydrophobia causes the diaphragm and respiratory muscles to contract. Evidence has shown upper motor nerve palsy weakness, increased tendon response, positive plantar reaction (Babinski reflex), paralysis of Vocal cords. Furthermore, Diplopia, facial muscle paralysis, and optic nerve neuritis occur. while the course of paralytic rabies is usually longer than furious and accounts for about 20% of cases (2, 10).
Eventually, in the fourth stage, the patient sinks into a coma then dies. The onset of clinical symptoms to death takes an average of 4 to 7 days. In rare cases with intensive care patients have a longer life expectancy.
To date, only 29 human rabies survivors have been reported worldwide. Three of them (10.35%) were treated with Milwaukee protocol and others were under intensive care survived. Accordingly, this method should be followed due to the fact that the treatment of rabies is possible (11).
The annual trend of animal bites is increasing in Iran. This rate has increased from 35.1 cases in 1987 to 167 cases in 2012 in 100,000 populations (12). To control animal bites, it is recommended that the veterinary and health networks of the cities take operational measures such as vaccination of endangered people, vaccination of pets, eradication of stray dogs, control of high-risk centers (areas or villages where the prevalence of animal bites is high), Attracting public participation, especially the creation and involvement of administrative officials and political advocacy of cities through raising the issue in the working group of health and food security of the city not only prevented rabies mortality but also reduced animal bites and reduced the economic and financial burden caused by Vaccine and serum were prepared. On the other hand, due to the efforts of public health officials to protect the population around the world from Covid-19 disease, it is essential to develop a strategy to monitor and prevent rabies during the COVID-19 epidemic. Unfortunately, in emergencies such as the Covid-19 pandemic, animal disease monitoring is ignored in infectious disease control programs. The true extent of Covid-19 damage may not be known for years or decades as uncontrolled diseases such as rabies increase during this time.
Funding: None
Acknowledgment We thank our colleagues who provided insight and expertise that greatly assisted the research.
Conflict of interest : Authors state no conflict of interest