Rehan Ahmad, Rukhsana Ateeq ur Rehman.
Dog Bite, Rabies and Vaccination Failure.
J Coll Physicians Surg Pak Jan ;11(6):397-8.

Objective: To highlight the health implications due to increasing population of stray dogs and outline the problems of post exposure prophylaxis. Design: Two case reports on rabies with failure of postexposure prophylaxis. Setting: Medical unit of the teaching hospital, Ayub Medical College, Abbottabad. Results: Both the cases developed rabies and expired despite postexposure rabies vaccination. First case presented with psychiatric features. Conclusion: Postexposure rabies vaccination should not be relied upon, in our health setup, unless its efficacy has been confirmed by measurement of protective antibody titre

Case 1: A young man aged 21 years was admitted to the medical unit with complaints of headache malaise and nausea for the last two days. There was no history of fever, cough, diarrhea head injury or drug addiction. On further questioning he confided that he was harbouring snakes in his throat. He attributed his illness to something taken in the train while coming from Karachi to Peshawar three days ago. He was found to be anxious and agitated, was slow to respond. Neurological examination of the cranial nerves, sensory motor system, deep tendon reflexes and planter response did not reveal any abnormality. There was no spinal tenderness or neck rigidity. Rest of the systemic examination was also not of any positive diagnostic avail. A tentative diagnosis of psychiatric illness, possibly schizophrenia was made while encephalitis could not be excluded at this stage. His preliminary blood tests and serum biochemistry was reported as normal as were his chest radiograph and C.T. scan of the brain. C.S.F report revealed three white blood cells /ml and protein content of 55 mg/dl. He was empirically started on third generation cephalosporins and was given benzodiazepizes. He developed lacrimation and hypersalivation during the next two days and he was found affirmative for hydrophobia and aerophobia. He was alleged to be bitten by the dog ayear ago but was vaccinated from the local dispensary. He went into coma on the first day of hospitalization and died of hypoapnea the next day. His attendants were advised postexposure prophylaxis for rabies.

Case 2: The second case of rabies was brought to the hospital with typical symptoms of rabies with aerophobia and hydrophobia and agitation. He drifted into coma over the next few days and was taken by the attendants to their home anticipating the impending death. He was bitten by the dog three months ago and was given vaccine from the office of the District Health Officer. The type of the vaccine and the vaccination schedule followed was not known.

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