Death Due to Rabies Despite on Time Post-Exposure Prophylaxis: A Case Report

Animal bites are a frequent reason for primary care and emergency department visits by children. Rabies is endemic in Iran, with 5 to 11 deaths reported annually. Over 90% of rabies cases in the country are caused by dog bites, and more than 50% of the victims are children under 15 years old. The mortality rate of rabies is 100%. A 4-year-old girl, who had been bitten by a dog and sustained facial lacerations 16 days prior to admission, presented with fever and loss of consciousness. Despite wound washing, receiving four doses of the rabies vaccine and immunoglobulin, and taking cephalexin on the fifth day after the bite, she developed rabies encephalitis. Rabies was confirmed through a skin biopsy and saliva PCR. Treatment included vancomycin, meropenem, and acyclovir in addition to favipiravir. The patient was intubated due to impaired consciousness and respiratory issues, and her hypertension was managed with medication. A brain CT scan showed normal findings. Cerebrospinal fluid analysis revealed protein at 52, glucose at 63, and no cellular presence. Vancomycin and acyclovir were discontinued when blood culture, wound culture, cerebrospinal fluid, and PCR results returned negative. Echocardiography results were acceptable, and the patient’s lab tests showed no other abnormalities except for leukocytosis at admission, an ESR of 60, and a CRP of 40. The patient remained intubated for two weeks and continued to receive supportive measures, ongoing drug therapy, ventilator adjustments, and water and electrolyte balance management. During hospitalization, she showed no response to the apnea test, oculovestibular reflex, or doll's eye maneuver. Two weeks later, she developed bradycardia and subsequently died, with a final diagnosis of furious rabies. Despite receiving the rabies vaccine and immunoglobulin, the patient died within a month of the bite, which may be attributed to the location of the bite on her face, the timing of her treatment, or the quality of the vaccine.