Pathogenesis of rabies in a pregnant HIV immune-compromised woman in Zambia: A case report

Rabies is a fatal neglected tropical zoonotic disease caused by neurotropic viruses of the genus Lyssavirus in the family Rhabdoviridae. We report the disease progression in a 30-year-old woman, in her eighth pregnancy, living with human immunodeficiency virus (HIV) on antiretroviral therapy (ART), who presented with neurological symptoms including aggression, restlessness, fever and vomiting 20 days following rabies exposure through multiple dog bites on the face and upper limbs. She had received a 4-dose regimen of rabies post-exposure prophylaxis (PEP), starting 2 days after exposure, with subsequent doses given 3 and 7 days later, while the 4th dose was administered 20 days after exposure. Wound washing was not performed, and rabies immunoglobulin was not administered as recommended by the World Health Organization for category 3 exposures. The disease rapidly progressed to rabies encephalitis, leading to death within 6 days of admission. Reverse transcriptase polymerase chain reaction (RT-PCR) performed on cerebral spinal fluid (<i>n</i> = 3) and nasopharyngeal swabs (<i>n</i> = 2) confirmed the diagnosis of rabies infection. Although the incubation period and symptomatology did not significantly deviate from documented classical cases, a compromised immunity evidenced by a low cluster of differentiation 4 (CD4) T-cell count of 382, coupled with non-adherence to recommended best practices for wound management and PEP administration, may have influenced the rapid disease progression. This case reveals the need for capacity building in health workers and the community to improve knowledge of rabies post-exposure response in Africa.