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Rabies Regimen Saves Teen Bitten by Bat

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WEDNESDAY, June 15 (HealthDay News) -- With the hope they might help save other lives, doctors from the Medical College of Wisconsin and Children's Hospital released specific information about the mixture of drugs they used to treat the first person ever known to survive rabies after symptoms had developed.

The 15-year-old girl was diagnosed with rabies in the fall of 2004, about one month after being bitten by a bat. Doctors treated her with a combination of antiviral drugs and medications that induced a coma, and then provided intensive care.

The specifics of the protocol used appear in the June 16 issue of the New England Journal of Medicine.

The eventual recovery of Jeanna Giese, of Fond du Lac, Wisc., remains remarkable, experts said.

If caught after symptoms develop, "Rabies is a 100 percent fatal illness," noted one of the treating physicians, Dr. Rodney Willoughby Jr., an associate professor of pediatrics at the Medical College of Wisconsin and Children's Hospital, Milwaukee.

Even though rabies is a clinically violent disorder, scientists have noted that there is virtually no damage done to the brain, according to Willoughby. That suggests that some sort of brain cell dysfunction, rather than brain cell death, is what kills people with rabies. Willoughby and his colleagues theorized that if they could dampen brain activity for a week or so, the immune system might have a chance to kill the rabies virus.

Rabies is a viral illness, most commonly transmitted through the bite of a wild animal, according to the CDC. It's rare in the United States, but is still responsible for about 55,000 deaths worldwide each year, according to background information in an editorial in the same issue of the journal.

The virus infects the central nervous system, and early symptoms include fever, headache and fatigue. Neurological symptoms, such as confusion, partial paralysis, anxiety and hypersalivation appear soon after. Ultimately, the virus causes death.

However, if someone seeks medical attention soon after being bitten by a wild or rabid domestic animal, prophylactic treatment can be started. Treatment begun before symptoms appear is nearly 100 percent effective in preventing the virus, according to the CDC.

In this case though, Giese didn't seek immediate medical attention after rescuing a bat that had been stuck in an interior window. Instead, she washed the tiny cut with peroxide. For a month after being bitten, the teenager went to school and played sports as she always had.

After a month, she began feeling fatigued and had a strange sensation in her left hand. Within days, she developed more symptoms, such as vomiting, double vision, tremors, slurred speech, partial paralysis and uncoordinated movements.

On the fifth day of symptoms, she was transferred to Children's Hospital in Wisconsin.

With the help of the CDC, Giese's doctors were quickly able to make the diagnosis of rabies because the girl had rabies antibodies present in her spinal fluid. A team of doctors, two from each specialty, was quickly assembled to come up with treatment options.

To give her body a chance to fight off the infection, the team decided to induce a coma and administer antiviral medications. The four medications used were: ketamine, midazolam, amantadine and ribavirin.

Ketamine is an anesthetic that can be used to induce coma. Midazolam is a sedative that causes drowsiness and can cause unconsciousness. According to Willoughby, midazolam can counteract some of the unwanted side effects of ketamine. Amantadine is an antiviral medication that also helps improve muscle coordination and has been used in the treatment of shaking from Parkinson's disease. Ribavirin is also an antiviral medication.

Giese also received intensive supportive care in the hospital. After eight days, the doctors slowly brought her out of the coma.

"We had a scary week or so, but she came back like gangbusters," Willoughby said.

Willoughby said the doctors aren't sure exactly which part of the treatment saved Giese from her infection, or whether using all the drugs in combination was key. They have supplied the protocol information to other doctors and other patients have been treated. Results from these patients will be published at a later time, Willoughby said.

"This report has shown that it is possible for a person to recover from rabies, even if they did not receive the rabies vaccine prior to the onset of their illness," said Dr. Alan C. Jackson, a professor of medicine and microbiology and immunology at Queen's University in Kingston, Ontario. Jackson authored the accompanying editorial.

"Exactly what we have learned from this case that should be applied to the management of future patients is hard to say. We don't know if one drug or a combination of drugs made an important difference and contributed to her survival," said Jackson, who added that it's also possible she had a less virulent strain of rabies.

Both Willoughby and Jackson emphasized the need for early treatment after a potential rabies exposure. And they stressed that simply being in close proximity to a bat may be enough to warrant concern. For example, individuals who have been sleeping in a room but then discover a bat should se their doctor, because bat bites are often so mild as to go unnoticed.

More information

To learn more about rabies, visit the National Library of Medicine.

SOURCES: Rodney Willoughby Jr., M.D., associate professor, pediatrics, Medical College of Wisconsin and Children's Hospital, Milwaukee; Alan C. Jackson, M.D., professor, medicine and microbiology and immunology, Queen's University, Kingston, Ontario; June 16, 2005, New England Journal of Medicine
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