logging in or signing up Rabies rabiezahran Download Post to : URL : Related Presentations : Share Add to Flag Embed Email Send to Blogs and Networks Add to Channel Uploaded from authorPOINT lite Insert YouTube videos in PowerPont slides with aS Desktop Copy embed code: (To copy code, click on the text box) Embed: URL: Thumbnail: WordPress Embed Customize Embed The presentation is successfully added In Your Favorites. Views: 863 Category: Education License: All Rights Reserved Like it (6) Dislike it (0) Added: July 21, 2010 This Presentation is Public Favorites: 1 Presentation Description No description available. Comments Posting comment... By: sumairaarif6869 (1 month(s) ago) sumaira_arif2009@live.com Saving..... Post Reply Close Saving..... Edit Comment Close By: jaspreet57 (14 month(s) ago) respected sir , please allow me to download this ppt. Saving..... Post Reply Close By: rabiezahran (14 month(s) ago) Dear sir,simply you can sign in to be able to download my ppt. Saving..... Edit Comment Close By: drrbw (17 month(s) ago) Respected sir, please allow me to download this ppt. Saving..... Post Reply Close Saving..... Edit Comment Close By: sunadhsunadh (18 month(s) ago) good excellent this would make me study better in research Saving..... Post Reply Close Saving..... Edit Comment Close By: pemba_72 (18 month(s) ago) please allow me to download this ppt!! Saving..... Post Reply Close Saving..... Edit Comment Close loading.... See all Premium member Presentation Transcript Rabies : Rabies Dr. Rabie Zahran. Tropical M. Consultant. Damietta Fever Hospital. Egypt rabiezahran@Gmail.com Slide 2: *Rabies is a zoonotic viral disease of the CNS. *It infect both domestic & wild animals. *It is one of the oldest & most feared diseases reported in medical text. Introduction rabiezahran@Gmail.com Slide 3: Introduction Practicing physicians must have a good idea about : * The biology, *Pathogenesis, *Epidemiology of the disease. *Detailed knowledge regarding post-exposure prophylaxis rabiezahran@Gmail.com Rabies is a global problem : Rabies is a global problem *Rabies is widely distributed across the globe. *More than 55 000 people die of rabies each y. *Human rabies cases have been documented in all continents except Australia and Antarctic. * 95% of human deaths occur in Asia & Africa. rabiezahran@Gmail.com Slide 5: Rabies is a global problem *Most human deaths follow a bite from an infected dog. *Between 30% to 60% of the victims of dog bites are children under the age of 15. rabiezahran@Gmail.com Slide 6: Rabies in Egypt rabiezahran@Gmail.com Slide 7: History * Rabies virus was recognized in Egypt before 2300 B.C. and was described by Aristotle ancient Greece. Who said, “Dogs suffer from the madness. This causes them to become irritable and all animals they bite to become diseased.” rabiezahran@Gmail.com Slide 8: * Dog bites are the causes for over 90% of all human post-exposure treatment in Egypt. Rabies in Egypt. rabiezahran@Gmail.com Slide 9: There is annual occurrence of stray dogs or wild canines bites for human. * No laboratory confirmation for the suspected cases. *All the bitten individuals are subjected to prophylactic treatment against Rabies including vaccination. Rabies in Egypt. rabiezahran@Gmail.com Slide 10: Control of stray dog population * The dog population is estimated at more than 3 million dogs. * The ratio of stray dogs to owned dogs is estimated to be 15 : 1 . Accordingly, the control measures are aimed mostly to eliminate stray dogs. rabiezahran@Gmail.com Slide 11: Control of stray dog population cont. * The current system for control of stray dog population is the elimination by poisoning with strychnine or by cartridge shooting. * These procedures create many problems with animal welfare organizations. rabiezahran@Gmail.com Slide 12: Causative agent rabiezahran@Gmail.com Slide 13: Causes Rabies is transmitted by contact with rabies virus. Most rabies viruses belong to: genus Lyssa-virus . family Rhabdo-viridae . (Greek word : Rhabdos =Road ) rabiezahran@Gmail.com Rabies virus : Rabies virus Bullet shaped virus Size is 180 x 75 nm Has Lipoprotein envelop Knob like spikes /Glycoprotein S Genome unsegmented Linear negative sense RNA. rabiezahran@Gmail.com Slide 15: Its nucleocapsid material comprises the Negri bodies observed in the cytoplasm of infected neurons. rabiezahran@Gmail.com Slide 16: rabiezahran@Gmail.com Slide 17: Rabies virus is sensitive to : *Ethanol. *Iodine. *Soap / Detergents. *Ether. *Chloroform. *Acetone. Destroyed at 500 c in 1 hour at 600 c in 5 minutes. rabiezahran@Gmail.com Slide 18: reservoir for rabies Any mammal can get rabies. rabiezahran@Gmail.com Dog is one of best human friendsbut can spread Rabies if not vaccinated : Dog is one of best human friendsbut can spread Rabies if not vaccinated rabiezahran@Gmail.com Slide 20: Dogs cats reservoir rabiezahran@Gmail.com Slide 21: reservoir Donkey Horse rabiezahran@Gmail.com Slide 22: Foxes Skunks reservoir الظربان rabiezahran@Gmail.com Slide 23: Raccoons reservoir Bats rabiezahran@Gmail.com Slide 24: cattle ferrets reservoir النمس rabiezahran@Gmail.com Slide 25: Rodents seldom carry rabies. NB. their bites generally do not require post-exposure prophylaxis. rabiezahran@Gmail.com Slide 26: lagomorphs (eg , hares) seldom carry rabies their bites generally do not require post-exposure prophylaxis. الأرانب البرية rabiezahran@Gmail.com Slide 27: Woodchucks are an exception and have been shown to carry rabies. So post-exposure prophylaxis is required rabiezahran@Gmail.com Slide 28: Those not mammals & so don’t carry rabies bird bees tick snake turtle rabiezahran@Gmail.com Slide 29: Rabies is transmitted through: Bite wound (5-80% of cases). Scratched , being licked over an open wound or mucus membrane, exposure to brain tissue or cerebrospinal fluid (CSF) of a rabid animal. Intact skin contact with urine, blood, or feces of an animal has not been shown to constitute exposure, except in bats. Where respiratory exposure from bats is a growing concern. Transmission rabiezahran@Gmail.com Slide 30: Direct human-to-human transmission of rabies has not been documented. However, 8 cases have been reported in which people died of rabies after transplantation of corneas from people who were diagnosed with the disease. All 8 occurred in transplanted corneas in 5 countries. rabiezahran@Gmail.com Slide 31: Incubation period Average : 20-90 days. Rarely : as long as 19 years. In > 90% of cases IP. <1 year. This depend upon : 1) size of inoculum . 2) size and depth of bite. 3) proximity to CNS. rabiezahran@Gmail.com Slide 32: rabiezahran@Gmail.com Slide 33: Pathogenesis rabiezahran@Gmail.com Slide 34: After inoculation, viral glycoprotein attaches to the nicotinic acetylcholine receptor of skeletal muscle. Initial replication occurs in myocytes. Pathogenesis rabiezahran@Gmail.com Slide 35: Pathogenesis *The virus then enters the nervous system via unmyelinated sensory and motor terminals. At this point, the virus is sequestered from the immune system, SO vaccination can no longer be effective. * The exact time course of these events is unknown because IP. may take years. rabiezahran@Gmail.com Slide 36: Pathogenesis *Rabies virus spreads via retrograde axoplasmic flow at 8-20 mm/d until it reaches the spinal cord. *Paresthesia then may begin at the wound site. *Rabies continues to spread throughout the CNS. undergoing centrifugal spread. rabiezahran@Gmail.com Slide 37: centrifugal spread along peripheral nerves to : *the skin, *Intestine, *salivary glands, where it is shed in saliva. * Cornea & shed in tears . Pathogenesis rabiezahran@Gmail.com Slide 38: PATHOGENESIS Live virus Epidermis, Mucus membrane Peripheral nerve CNS ( gray matter ) Other tissue (salivary glands,…) centripetally centrifugally rabiezahran@Gmail.com Slide 39: rabiezahran@Gmail.com Signs in animals that may suspect to be rabid : Signs in animals that may suspect to be rabid Unusual behavior. Wild animals that appear friendly. Nocturnal animals active during the day An increase in drool or saliva. Animals that act very sick. Animals that have difficulty moving or are dead rabiezahran@Gmail.com Slide 41: rabiezahran@Gmail.com Rabid dog Slide 42: rabiezahran@Gmail.com Rabid dog with dripping saliva Slide 43: rabiezahran@Gmail.com two dogs afflicted with dumb rabies, manifested as depression, and an attempt at self-imposed isolation Slide 44: rabiezahran@Gmail.com Rabid fox in wooded area Slide 45: rabiezahran@Gmail.com Depressed rabid fox Slide 46: Clinical rabiezahran@Gmail.com Slide 47: Clinical presentation (Leads the clues in Diagnosis) 1) history of or evidence of : *an animal bite, *death of the biting animal, *incomplete or no vaccination following exposure. 2) clinical symptoms and signs, rabiezahran@Gmail.com Broad category - Presentations : Broad category - Presentations Furious Rabies Dumb ( Rage tranquille ) (Landry/Guillain-Barre Syndrome Slide 49: Once symptoms of rabies develop it is fatal to both animal and human rabiezahran@Gmail.com Slide 50: Clinical Course * Rabies progresses over 7 to 14 days . * The mean time between initial presentation and death is 16.2 days. rabiezahran@Gmail.com Slide 51: Clinical Course Non specific Prodrome : 1 - 2 days 10 days. Fever, headache, sore throat Anorexia, nausea, vomiting, Agitation, depression Paresthesias or fasciculation at or Around the site of inoculation of virus. rabiezahran@Gmail.com Slide 52: Clinical Course The only symptom that specifically arias the Red Flag of rabies diagnosis is Paresthesias and pain at the site of bite or scratch during the Prodrome. rabiezahran@Gmail.com Acute Neurologic Encephalitis(symptoms) : Acute Neurologic Encephalitis(symptoms) 1 – 2 days to < 1 week Excessive motor activity, Excitation, Agitation Confusion, Hallucinations, Delirium, Bizarre aberrations of thought, Seizures, Muscle spasms, Meningismus , Opisthotonic posturing Mental aberration ( Lucid period coma ) Hyper salivation, Aphasia, Pharyngeal spasms Incordination , Hyperactivity Clinical Course rabiezahran@Gmail.com Acute Neurologic Encephalitis(signs) : Acute Neurologic Encephalitis(signs) Fever T > 40.6 Dilated irregular pupils Lacrimation , Salivation & Perspiration Upper motor neuron paralysis Deep tendon reflexes Extensor plantar responses ( as a rule ) Hydrophobia or Aerophobia (50 -70% ) Clinical Course rabiezahran@Gmail.com Slide 55: Late symptoms : Hypotension. Coma. DIC. Cardiac arrhythmias. Cardiac arrest. Clinical Course rabiezahran@Gmail.com Rabies can present as Grave condition : Rabies can present as Grave condition rabiezahran@Gmail.com Slide 57: rabiezahran@Gmail.com Slide 58: Clinical diagnosis in humans. Classical signs of brain involvement include : spasm in response to stimuli either : * Tactile. * Auditory. * Visual. *Olfactory. e g : aerophobia and hydrophobia. rabiezahran@Gmail.com Slide 59: Clinical diagnosis in humans. Periods of lucidity, agitation , confusion, Signs of autonomic dysfunctions. Spontaneous inspiratory spasms until death (there presence facilitate clinical diagnosis). At early paralytic rabies myoedema is noted at percussion sites on the chest , deltoid and thigh. rabiezahran@Gmail.com Slide 60: Atypical or non classic rabies is being increasingly recognized and may be responsible for underreporting. rabiezahran@Gmail.com Slide 61: Role of imaging: 1: MRI of brain: Abnormal , ill-defined , mildly hyper signal T2 images of the brain are suggestive of rabies. 2: CT of brain : Is of no diagnostic value. rabiezahran@Gmail.com Lab . Studies : Lab . Studies 1: CSF : * may be normal . * protein may be elevated. * mild increase of CSF white blood cells. * Isolation of rabies virus from CSF (also from saliva ). * Rabies neutralizing antibody titer in the CSF (or serum) is higher than 5 in unvaccinated people. rabiezahran@Gmail.com Common confirmatory test : Common confirmatory test 1)The standard pre-mortem test is Direct fluorescent antibody test to demonstrate the presence of viral antigen. 2)The standard post-mortem test is biopsy of the patient's brain and examination for Negri b. Autopsies are rarely performed. rabiezahran@Gmail.com Negri bodies – A gold standard in Diagnosis : Negri bodies – A gold standard in Diagnosis Inclusion bodies called Negri bodies are 100% diagnostic for rabies infection, but found only in 20% of cases rabiezahran@Gmail.com Negri bodies in Brain Tissue : Negri bodies in Brain Tissue Negri bodies round or oval inclusion bodies seen in the cytoplasm and sometimes in the processes of neurons of rabid animals after death. Negri bodies are Eosino-philic, sharply outlined, (2-10 µm in diameter) pathognomonic for diagnosis. rabiezahran@Gmail.com Slide 66: DIFFERENTIAL DIAGNOSIS Other viral encephalitis Hysteria reaction to animal bite Landry/ Guillan - barre syndrome Poliomyelitis Allergic encephalomyelitis ( rabies vaccine ) rabiezahran@Gmail.com Slide 67: rabiezahran@Gmail.com PREVENTION Slide 68: PREVENTION Pre-exposure Prophylaxis Post-exposure Prophylaxis rabiezahran@Gmail.com 1st Vaccine for Rabies : 1st Vaccine for Rabies Prepared by Pasteur by drying various periods pieces of spinal cord of Rabbits infected with fixed virus 1885 Joseph Meister 9 year boy vaccinated 13 injections were given Patient saved rabiezahran@Gmail.com Cell culture Vaccines in – commonly prescribed : Cell culture Vaccines in – commonly prescribed 1 Human diploid cell vaccine. 2 Purified chick embryo cell vaccine 3.Purified Vero cell vaccine Human Diploid CellVaccine : Human Diploid CellVaccine Koprowsky, Viktor, Plokin discovered Inactivated in Betaproprionate. No serious side effects. Human Diploid cell vaccines purified . Sub Unit vaccines in progress/developed. Pre-exposure vaccination : Pre-exposure vaccination Indicated for : 1) Laboratory workers. 2) Veterinarians. 3) technical staff. 4) Bat handlers. 5) International travelers (who are likely to come in contact with animals in parts of the world where rabies is common.) rabiezahran@Gmail.com Human Diploid Cell VaccinesInactivated forms of virus that promote immunity by inducing an active immune response. : Human Diploid Cell VaccinesInactivated forms of virus that promote immunity by inducing an active immune response. * Pre-exposure prophylaxis ( 3 doses ) 0 – 7 – 21 or 28 days A booster after 1 year, Repeat once in 5 days, Given IM or SC in the Deltoid region. Don't inject in Gluteal region. rabiezahran@Gmail.com Slide 74: Vaccination is the best way to prevent infection and properly vaccinated animals stand very little chance of contracting the disease. While rabies vaccination for dogs is mandatory for all states, it is estimated that up to half of all dogs are not vaccinated rabiezahran@Gmail.com Slide 75: Post-exposure care Prophylaxis rabiezahran@Gmail.com Slide 76: rabiezahran@Gmail.com The good news is that if post-exposure treatment is given correctly and in time, it is 100% effective in preventing rabies disease. Slide 77: Post-exposure care : rabiezahran@Gmail.com Slide 78: Post-exposure care : rabiezahran@Gmail.com Slide 79: * don't suture . * Use local antiseptics or tincture of Iodine. * Inform your doctor immediately Post-exposure care : rabiezahran@Gmail.com Slide 80: rabiezahran@Gmail.com Once the diagnosis of rabies is confirmed : Considering the hopelessness of rabies in man TTT. Should centre on comfort care: 1: the patient should receive adequate sedation & comfort in a private room with suitable emotional and physical support . 2: Repeated IV . Morphine is effective in reliving severe agitation, anxiety and phonic spasms. 3: Invasive procedures should be avoided. Slide 81: Post-exposure Prophylaxis rabiezahran@Gmail.com Category - WHO : Category - WHO Category I: touching or feeding suspect animals, but skin is intact. Category II: minor scratches without bleeding from contact, or licks on broken skin . Category III: one or more bites, scratches, licks on broken skin, or other contact that breaks the skin; or exposure to bats rabiezahran@Gmail.com Slide 83: Anti rabies vaccine should be given for: category II & III exposures as soon as possible according to WHO. Recognized regimen. rabiezahran@Gmail.com Slide 84: Anti rabies immunoglobulin( antibodies ) should be given (with 1st dose anti-rabies vaccine ) to : Category III exposures . Category II ( if the patient is immunocopromized.) rabiezahran@Gmail.com Slide 85: rabiezahran@Gmail.com This Passive antibody provides protection for 1-2 weeks until the vaccine elicits protective antibody. Slide 86: Identify and capture the animal involved . Post exposure prophylaxis should start immediately and can be stopped if the animal remains healthy after 10 days rabiezahran@Gmail.com In case of category III exposure : Human Diploid Cell Vaccines : Human Diploid Cell Vaccines *Post exposure Prophylaxis: 5 doses at : 0 -3 -7-14 – 28 days. Given IM or SC in the Deltoid region. Don't inject in Gluteal region. rabiezahran@Gmail.com Slide 88: rabiezahran@Gmail.com A person who has been previously vaccinated should get 2 doses of rabies vaccine At 0 & 3rd day * Rabies Immune Globulin is not needed Slide 89: rabiezahran@Gmail.com Pregnancy & Rabies vaccine Slide 90: rabiezahran@Gmail.com Pregnancy is not a contraindication to post-exposure prophylaxis against rabies, which is warranted to protect the life of the fetus and mother. *No adverse pregnancy outcomes have been documented with post-exposure prophylaxis. *No mother-to-fetus transmission has been described; Slide 91: rabiezahran@Gmail.com *thus, neither rabies exposure nor diagnosis of rabies in the mother is an indication for pregnancy termination Slide 92: rabiezahran@Gmail.com Steroids which are usually indicated in the treatment of local vaccine reactions or cerebral edema, are contraindicated because they : mortality noted in animal studies they reduce the response to the vaccine. Slide 93: rabiezahran@Gmail.com References emedicine web site. CDC web site. Guidelines for infectious diseases (Imbaba fever hospital web site.) Google gallery. Vaccine Information.org *Current situation of Rabies in Egypt ( by Prof.Dr.Hamed Samaha Chairman, General Organization for Veterinary Services) You can show my educational presentation at(autherstream.com ) Slide 94: Thank you. rabiezahran@Gmail.com You do not have the permission to view this presentation. In order to view it, please contact the author of the presentation.
Rabies rabiezahran Download Post to : URL : Related Presentations : Share Add to Flag Embed Email Send to Blogs and Networks Add to Channel Uploaded from authorPOINT lite Insert YouTube videos in PowerPont slides with aS Desktop Copy embed code: (To copy code, click on the text box) Embed: URL: Thumbnail: WordPress Embed Customize Embed The presentation is successfully added In Your Favorites. Views: 863 Category: Education License: All Rights Reserved Like it (6) Dislike it (0) Added: July 21, 2010 This Presentation is Public Favorites: 1 Presentation Description No description available. Comments Posting comment... By: sumairaarif6869 (1 month(s) ago) sumaira_arif2009@live.com Saving..... Post Reply Close Saving..... Edit Comment Close By: jaspreet57 (14 month(s) ago) respected sir , please allow me to download this ppt. Saving..... Post Reply Close By: rabiezahran (14 month(s) ago) Dear sir,simply you can sign in to be able to download my ppt. Saving..... Edit Comment Close By: drrbw (17 month(s) ago) Respected sir, please allow me to download this ppt. Saving..... Post Reply Close Saving..... Edit Comment Close By: sunadhsunadh (18 month(s) ago) good excellent this would make me study better in research Saving..... Post Reply Close Saving..... Edit Comment Close By: pemba_72 (18 month(s) ago) please allow me to download this ppt!! Saving..... Post Reply Close Saving..... Edit Comment Close loading.... See all Premium member Presentation Transcript Rabies : Rabies Dr. Rabie Zahran. Tropical M. Consultant. Damietta Fever Hospital. Egypt rabiezahran@Gmail.com Slide 2: *Rabies is a zoonotic viral disease of the CNS. *It infect both domestic & wild animals. *It is one of the oldest & most feared diseases reported in medical text. Introduction rabiezahran@Gmail.com Slide 3: Introduction Practicing physicians must have a good idea about : * The biology, *Pathogenesis, *Epidemiology of the disease. *Detailed knowledge regarding post-exposure prophylaxis rabiezahran@Gmail.com Rabies is a global problem : Rabies is a global problem *Rabies is widely distributed across the globe. *More than 55 000 people die of rabies each y. *Human rabies cases have been documented in all continents except Australia and Antarctic. * 95% of human deaths occur in Asia & Africa. rabiezahran@Gmail.com Slide 5: Rabies is a global problem *Most human deaths follow a bite from an infected dog. *Between 30% to 60% of the victims of dog bites are children under the age of 15. rabiezahran@Gmail.com Slide 6: Rabies in Egypt rabiezahran@Gmail.com Slide 7: History * Rabies virus was recognized in Egypt before 2300 B.C. and was described by Aristotle ancient Greece. Who said, “Dogs suffer from the madness. This causes them to become irritable and all animals they bite to become diseased.” rabiezahran@Gmail.com Slide 8: * Dog bites are the causes for over 90% of all human post-exposure treatment in Egypt. Rabies in Egypt. rabiezahran@Gmail.com Slide 9: There is annual occurrence of stray dogs or wild canines bites for human. * No laboratory confirmation for the suspected cases. *All the bitten individuals are subjected to prophylactic treatment against Rabies including vaccination. Rabies in Egypt. rabiezahran@Gmail.com Slide 10: Control of stray dog population * The dog population is estimated at more than 3 million dogs. * The ratio of stray dogs to owned dogs is estimated to be 15 : 1 . Accordingly, the control measures are aimed mostly to eliminate stray dogs. rabiezahran@Gmail.com Slide 11: Control of stray dog population cont. * The current system for control of stray dog population is the elimination by poisoning with strychnine or by cartridge shooting. * These procedures create many problems with animal welfare organizations. rabiezahran@Gmail.com Slide 12: Causative agent rabiezahran@Gmail.com Slide 13: Causes Rabies is transmitted by contact with rabies virus. Most rabies viruses belong to: genus Lyssa-virus . family Rhabdo-viridae . (Greek word : Rhabdos =Road ) rabiezahran@Gmail.com Rabies virus : Rabies virus Bullet shaped virus Size is 180 x 75 nm Has Lipoprotein envelop Knob like spikes /Glycoprotein S Genome unsegmented Linear negative sense RNA. rabiezahran@Gmail.com Slide 15: Its nucleocapsid material comprises the Negri bodies observed in the cytoplasm of infected neurons. rabiezahran@Gmail.com Slide 16: rabiezahran@Gmail.com Slide 17: Rabies virus is sensitive to : *Ethanol. *Iodine. *Soap / Detergents. *Ether. *Chloroform. *Acetone. Destroyed at 500 c in 1 hour at 600 c in 5 minutes. rabiezahran@Gmail.com Slide 18: reservoir for rabies Any mammal can get rabies. rabiezahran@Gmail.com Dog is one of best human friendsbut can spread Rabies if not vaccinated : Dog is one of best human friendsbut can spread Rabies if not vaccinated rabiezahran@Gmail.com Slide 20: Dogs cats reservoir rabiezahran@Gmail.com Slide 21: reservoir Donkey Horse rabiezahran@Gmail.com Slide 22: Foxes Skunks reservoir الظربان rabiezahran@Gmail.com Slide 23: Raccoons reservoir Bats rabiezahran@Gmail.com Slide 24: cattle ferrets reservoir النمس rabiezahran@Gmail.com Slide 25: Rodents seldom carry rabies. NB. their bites generally do not require post-exposure prophylaxis. rabiezahran@Gmail.com Slide 26: lagomorphs (eg , hares) seldom carry rabies their bites generally do not require post-exposure prophylaxis. الأرانب البرية rabiezahran@Gmail.com Slide 27: Woodchucks are an exception and have been shown to carry rabies. So post-exposure prophylaxis is required rabiezahran@Gmail.com Slide 28: Those not mammals & so don’t carry rabies bird bees tick snake turtle rabiezahran@Gmail.com Slide 29: Rabies is transmitted through: Bite wound (5-80% of cases). Scratched , being licked over an open wound or mucus membrane, exposure to brain tissue or cerebrospinal fluid (CSF) of a rabid animal. Intact skin contact with urine, blood, or feces of an animal has not been shown to constitute exposure, except in bats. Where respiratory exposure from bats is a growing concern. Transmission rabiezahran@Gmail.com Slide 30: Direct human-to-human transmission of rabies has not been documented. However, 8 cases have been reported in which people died of rabies after transplantation of corneas from people who were diagnosed with the disease. All 8 occurred in transplanted corneas in 5 countries. rabiezahran@Gmail.com Slide 31: Incubation period Average : 20-90 days. Rarely : as long as 19 years. In > 90% of cases IP. <1 year. This depend upon : 1) size of inoculum . 2) size and depth of bite. 3) proximity to CNS. rabiezahran@Gmail.com Slide 32: rabiezahran@Gmail.com Slide 33: Pathogenesis rabiezahran@Gmail.com Slide 34: After inoculation, viral glycoprotein attaches to the nicotinic acetylcholine receptor of skeletal muscle. Initial replication occurs in myocytes. Pathogenesis rabiezahran@Gmail.com Slide 35: Pathogenesis *The virus then enters the nervous system via unmyelinated sensory and motor terminals. At this point, the virus is sequestered from the immune system, SO vaccination can no longer be effective. * The exact time course of these events is unknown because IP. may take years. rabiezahran@Gmail.com Slide 36: Pathogenesis *Rabies virus spreads via retrograde axoplasmic flow at 8-20 mm/d until it reaches the spinal cord. *Paresthesia then may begin at the wound site. *Rabies continues to spread throughout the CNS. undergoing centrifugal spread. rabiezahran@Gmail.com Slide 37: centrifugal spread along peripheral nerves to : *the skin, *Intestine, *salivary glands, where it is shed in saliva. * Cornea & shed in tears . Pathogenesis rabiezahran@Gmail.com Slide 38: PATHOGENESIS Live virus Epidermis, Mucus membrane Peripheral nerve CNS ( gray matter ) Other tissue (salivary glands,…) centripetally centrifugally rabiezahran@Gmail.com Slide 39: rabiezahran@Gmail.com Signs in animals that may suspect to be rabid : Signs in animals that may suspect to be rabid Unusual behavior. Wild animals that appear friendly. Nocturnal animals active during the day An increase in drool or saliva. Animals that act very sick. Animals that have difficulty moving or are dead rabiezahran@Gmail.com Slide 41: rabiezahran@Gmail.com Rabid dog Slide 42: rabiezahran@Gmail.com Rabid dog with dripping saliva Slide 43: rabiezahran@Gmail.com two dogs afflicted with dumb rabies, manifested as depression, and an attempt at self-imposed isolation Slide 44: rabiezahran@Gmail.com Rabid fox in wooded area Slide 45: rabiezahran@Gmail.com Depressed rabid fox Slide 46: Clinical rabiezahran@Gmail.com Slide 47: Clinical presentation (Leads the clues in Diagnosis) 1) history of or evidence of : *an animal bite, *death of the biting animal, *incomplete or no vaccination following exposure. 2) clinical symptoms and signs, rabiezahran@Gmail.com Broad category - Presentations : Broad category - Presentations Furious Rabies Dumb ( Rage tranquille ) (Landry/Guillain-Barre Syndrome Slide 49: Once symptoms of rabies develop it is fatal to both animal and human rabiezahran@Gmail.com Slide 50: Clinical Course * Rabies progresses over 7 to 14 days . * The mean time between initial presentation and death is 16.2 days. rabiezahran@Gmail.com Slide 51: Clinical Course Non specific Prodrome : 1 - 2 days 10 days. Fever, headache, sore throat Anorexia, nausea, vomiting, Agitation, depression Paresthesias or fasciculation at or Around the site of inoculation of virus. rabiezahran@Gmail.com Slide 52: Clinical Course The only symptom that specifically arias the Red Flag of rabies diagnosis is Paresthesias and pain at the site of bite or scratch during the Prodrome. rabiezahran@Gmail.com Acute Neurologic Encephalitis(symptoms) : Acute Neurologic Encephalitis(symptoms) 1 – 2 days to < 1 week Excessive motor activity, Excitation, Agitation Confusion, Hallucinations, Delirium, Bizarre aberrations of thought, Seizures, Muscle spasms, Meningismus , Opisthotonic posturing Mental aberration ( Lucid period coma ) Hyper salivation, Aphasia, Pharyngeal spasms Incordination , Hyperactivity Clinical Course rabiezahran@Gmail.com Acute Neurologic Encephalitis(signs) : Acute Neurologic Encephalitis(signs) Fever T > 40.6 Dilated irregular pupils Lacrimation , Salivation & Perspiration Upper motor neuron paralysis Deep tendon reflexes Extensor plantar responses ( as a rule ) Hydrophobia or Aerophobia (50 -70% ) Clinical Course rabiezahran@Gmail.com Slide 55: Late symptoms : Hypotension. Coma. DIC. Cardiac arrhythmias. Cardiac arrest. Clinical Course rabiezahran@Gmail.com Rabies can present as Grave condition : Rabies can present as Grave condition rabiezahran@Gmail.com Slide 57: rabiezahran@Gmail.com Slide 58: Clinical diagnosis in humans. Classical signs of brain involvement include : spasm in response to stimuli either : * Tactile. * Auditory. * Visual. *Olfactory. e g : aerophobia and hydrophobia. rabiezahran@Gmail.com Slide 59: Clinical diagnosis in humans. Periods of lucidity, agitation , confusion, Signs of autonomic dysfunctions. Spontaneous inspiratory spasms until death (there presence facilitate clinical diagnosis). At early paralytic rabies myoedema is noted at percussion sites on the chest , deltoid and thigh. rabiezahran@Gmail.com Slide 60: Atypical or non classic rabies is being increasingly recognized and may be responsible for underreporting. rabiezahran@Gmail.com Slide 61: Role of imaging: 1: MRI of brain: Abnormal , ill-defined , mildly hyper signal T2 images of the brain are suggestive of rabies. 2: CT of brain : Is of no diagnostic value. rabiezahran@Gmail.com Lab . Studies : Lab . Studies 1: CSF : * may be normal . * protein may be elevated. * mild increase of CSF white blood cells. * Isolation of rabies virus from CSF (also from saliva ). * Rabies neutralizing antibody titer in the CSF (or serum) is higher than 5 in unvaccinated people. rabiezahran@Gmail.com Common confirmatory test : Common confirmatory test 1)The standard pre-mortem test is Direct fluorescent antibody test to demonstrate the presence of viral antigen. 2)The standard post-mortem test is biopsy of the patient's brain and examination for Negri b. Autopsies are rarely performed. rabiezahran@Gmail.com Negri bodies – A gold standard in Diagnosis : Negri bodies – A gold standard in Diagnosis Inclusion bodies called Negri bodies are 100% diagnostic for rabies infection, but found only in 20% of cases rabiezahran@Gmail.com Negri bodies in Brain Tissue : Negri bodies in Brain Tissue Negri bodies round or oval inclusion bodies seen in the cytoplasm and sometimes in the processes of neurons of rabid animals after death. Negri bodies are Eosino-philic, sharply outlined, (2-10 µm in diameter) pathognomonic for diagnosis. rabiezahran@Gmail.com Slide 66: DIFFERENTIAL DIAGNOSIS Other viral encephalitis Hysteria reaction to animal bite Landry/ Guillan - barre syndrome Poliomyelitis Allergic encephalomyelitis ( rabies vaccine ) rabiezahran@Gmail.com Slide 67: rabiezahran@Gmail.com PREVENTION Slide 68: PREVENTION Pre-exposure Prophylaxis Post-exposure Prophylaxis rabiezahran@Gmail.com 1st Vaccine for Rabies : 1st Vaccine for Rabies Prepared by Pasteur by drying various periods pieces of spinal cord of Rabbits infected with fixed virus 1885 Joseph Meister 9 year boy vaccinated 13 injections were given Patient saved rabiezahran@Gmail.com Cell culture Vaccines in – commonly prescribed : Cell culture Vaccines in – commonly prescribed 1 Human diploid cell vaccine. 2 Purified chick embryo cell vaccine 3.Purified Vero cell vaccine Human Diploid CellVaccine : Human Diploid CellVaccine Koprowsky, Viktor, Plokin discovered Inactivated in Betaproprionate. No serious side effects. Human Diploid cell vaccines purified . Sub Unit vaccines in progress/developed. Pre-exposure vaccination : Pre-exposure vaccination Indicated for : 1) Laboratory workers. 2) Veterinarians. 3) technical staff. 4) Bat handlers. 5) International travelers (who are likely to come in contact with animals in parts of the world where rabies is common.) rabiezahran@Gmail.com Human Diploid Cell VaccinesInactivated forms of virus that promote immunity by inducing an active immune response. : Human Diploid Cell VaccinesInactivated forms of virus that promote immunity by inducing an active immune response. * Pre-exposure prophylaxis ( 3 doses ) 0 – 7 – 21 or 28 days A booster after 1 year, Repeat once in 5 days, Given IM or SC in the Deltoid region. Don't inject in Gluteal region. rabiezahran@Gmail.com Slide 74: Vaccination is the best way to prevent infection and properly vaccinated animals stand very little chance of contracting the disease. While rabies vaccination for dogs is mandatory for all states, it is estimated that up to half of all dogs are not vaccinated rabiezahran@Gmail.com Slide 75: Post-exposure care Prophylaxis rabiezahran@Gmail.com Slide 76: rabiezahran@Gmail.com The good news is that if post-exposure treatment is given correctly and in time, it is 100% effective in preventing rabies disease. Slide 77: Post-exposure care : rabiezahran@Gmail.com Slide 78: Post-exposure care : rabiezahran@Gmail.com Slide 79: * don't suture . * Use local antiseptics or tincture of Iodine. * Inform your doctor immediately Post-exposure care : rabiezahran@Gmail.com Slide 80: rabiezahran@Gmail.com Once the diagnosis of rabies is confirmed : Considering the hopelessness of rabies in man TTT. Should centre on comfort care: 1: the patient should receive adequate sedation & comfort in a private room with suitable emotional and physical support . 2: Repeated IV . Morphine is effective in reliving severe agitation, anxiety and phonic spasms. 3: Invasive procedures should be avoided. Slide 81: Post-exposure Prophylaxis rabiezahran@Gmail.com Category - WHO : Category - WHO Category I: touching or feeding suspect animals, but skin is intact. Category II: minor scratches without bleeding from contact, or licks on broken skin . Category III: one or more bites, scratches, licks on broken skin, or other contact that breaks the skin; or exposure to bats rabiezahran@Gmail.com Slide 83: Anti rabies vaccine should be given for: category II & III exposures as soon as possible according to WHO. Recognized regimen. rabiezahran@Gmail.com Slide 84: Anti rabies immunoglobulin( antibodies ) should be given (with 1st dose anti-rabies vaccine ) to : Category III exposures . Category II ( if the patient is immunocopromized.) rabiezahran@Gmail.com Slide 85: rabiezahran@Gmail.com This Passive antibody provides protection for 1-2 weeks until the vaccine elicits protective antibody. Slide 86: Identify and capture the animal involved . Post exposure prophylaxis should start immediately and can be stopped if the animal remains healthy after 10 days rabiezahran@Gmail.com In case of category III exposure : Human Diploid Cell Vaccines : Human Diploid Cell Vaccines *Post exposure Prophylaxis: 5 doses at : 0 -3 -7-14 – 28 days. Given IM or SC in the Deltoid region. Don't inject in Gluteal region. rabiezahran@Gmail.com Slide 88: rabiezahran@Gmail.com A person who has been previously vaccinated should get 2 doses of rabies vaccine At 0 & 3rd day * Rabies Immune Globulin is not needed Slide 89: rabiezahran@Gmail.com Pregnancy & Rabies vaccine Slide 90: rabiezahran@Gmail.com Pregnancy is not a contraindication to post-exposure prophylaxis against rabies, which is warranted to protect the life of the fetus and mother. *No adverse pregnancy outcomes have been documented with post-exposure prophylaxis. *No mother-to-fetus transmission has been described; Slide 91: rabiezahran@Gmail.com *thus, neither rabies exposure nor diagnosis of rabies in the mother is an indication for pregnancy termination Slide 92: rabiezahran@Gmail.com Steroids which are usually indicated in the treatment of local vaccine reactions or cerebral edema, are contraindicated because they : mortality noted in animal studies they reduce the response to the vaccine. Slide 93: rabiezahran@Gmail.com References emedicine web site. CDC web site. Guidelines for infectious diseases (Imbaba fever hospital web site.) Google gallery. Vaccine Information.org *Current situation of Rabies in Egypt ( by Prof.Dr.Hamed Samaha Chairman, General Organization for Veterinary Services) You can show my educational presentation at(autherstream.com ) Slide 94: Thank you. rabiezahran@Gmail.com