tm1 k15 rabies mahasiswa
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RABIES
INFECTIOUS AND TROPICAL DISEASE DIVISION
DEPARTMENT OF PEDIATRICS
FACULTY OF MEDICINE
UNIVERSITY OF NORTH SUMATERA
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ConclusionsChocolate consumption enhances
cognitive function, which is a sinequa non for winning the NobelPrize, and it is closely correlatedwith the number of Nobellaureates in each country.
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RABIES VIRUS
Rabies virus is a member of the genus Lyssavirus in the family
Rhabdoviridae. The viruses are bullet shape with 10-nm spike
like glycoprotein peplomers covering the surface.
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Rabies is spread to people through close contact with infected
saliva via bites or scratches.
Though transmission has been rarely documented via other
routes such as contamination of mucous membranes (i.e. eyes,
nose, mouth), aerosol transmission, and corneal and organ
transplantations.
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RABIES
Rabies is a zoonotic disease (a disease that is transmitted from
animals to humans) that is caused by a virus.
All species of mammals are susceptible to rabies virus infection,but only a few species are important as reservoirs of the disease.
Domestic dogs, cats, cattle, foxes, raccoons, bats, ferrets,
skunks.
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INCUBATION PERIOD
The incubation period is typically 1 3 months, but may vary
from < 1 week to > 1 year.
Incubation period is shorter in children, and the nearer the bite isto the head the shorter the incubation period.
It also depends on the severity of wound.
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RESPONSE TO INFECTION
Following a rabid bite, no immune response is detectable in
unvaccinated subjects before encephalitis has developed.
Rabies antibody is found in serum, then in CSF at least a week
after the onset.Pleocytosis is observed in only 60% of patients.
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SYMPTOMS
Prodromal Symptoms
Itching or paraesthesiae at the site of the healed bite wound in 40% ofpatients
Nonspecific symptoms including fever, headache, myalgia, fatigue, sore
throat, gastrointestinal symptoms, irritability, anxiety and insomnia.The disease progresses within 1 week.
Common Symptoms
1. Itching at the healed bite wound
2. Hydrophobic spasms
3. Aerophobia
4. Feeling of terror
5. Aggression
6. Hypersalivation
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FURIOUS VS PARALYTIC
Furious (Encephalitic) Rabies
Occurred in 80% of cases.
Fever, confusion, hallucinations, combativeness, muscle spasms,
hyperactivity and seizures.
Autonomic dysfunction including hypersalivation, excessive
perspiration, gooseflesh, pupillary dilation and/or priapism.
Hydrophobia and aerophobia: involuntary, painful contraction of
the diaphragm and accessory respiratory, laryngeal andpharyngeal muscles in response to swallowing liquids
(hydrophobia) or a draft of air (aerophobia).
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Hypersalivation and pharyngeal dysfunction resulted in
appearance offoaming at the mouth
Episodes ofexcitation, aggression, anxiety or hallucinations
interspersed with periods of calm lucidity.Cranial nerve lesions (III, VII and IX)
Coma followed withing days by death.
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FURIOUS VS PARALYTIC
Paralytic (Dumb) Rabies
Less common.
Prodromal symptoms are followed by paraesthesiae or
hypotonic weakness.
Started near the site of the bite and spreading cranially.
Ascending paralysis results in constipation, urinary retention,
respiratory failure and inability to swallow.
Hydrophobic spasms may occur in terminal phase and death
after 1-3 weeks.
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DIFFERENTIAL DIAGNOSIS
Tetanus
Intoxication
GuillainBarre syndrome
Other viral encephalomyelitides
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DIAGNOSIS
Laboratory is usually normal initially.
Complete blood counts are usually normal.
CSF may reveals mild mononuclear cell pleocytosis, with a mildly
elevated protein level.
Diagnostic useful specimens: serum, CSF, fresh saliva, braintissue, skin biopsy from the neck (must include at least 10 hairfollicles)
Rabies virus-specific antibodies
RT-PCR
DFA
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BITE AND SCRATCH WOUND
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LOCAL TREATMENT
Prompt local treatment of all bite wounds and scratches.
Immediate and thorough flushing and washing of the wound for
a minimum of 15 minutes with soap and water, or detergent.
Followed by application of 70% ethanol or povidone-iodinesolution.
The wound closure, if possible, should not be sutured.
Tetanus toxoid and antibiotics for other infection (if needed).
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CATEGORIES OF
CONTACT AND RECOMMENDED PEP
Categories of contact withsuspected rabid animal
Post-exposure prophylaxis measures
Category ITouching or feeding animals, licks of
intact skin
None
Category IINibbling of uncovered skin, minorscratches or abrasions withoutbleeding
Immediate vaccination and localtreatment of the wound
Category IIISingle or multiple transdermal bites orscratches, licks on broken skin;contamination of mucous membranewith saliva from licks, contacts withbats
Immediate vaccination andadministration of rabiesimmunoglobulin; local treatment ofthe wound
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History of animal bite (dog, cat, monkey)
Animal is missing or death Animal can be observed for 10-14 days
High riskwound
Low riskwound
Give Rabiesvaccine &
Rabies IG
Give Rabiesvaccine
Check the specimen ofanimal brain
Positive Negative
Continuevaccine
Stopvaccine
If brain specimen is not
checked, continue vaccine
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History of animal bite (dog, cat, monkey)
Animal is missing or death Animal can be observed for 10-14 days
High riskwound
Low riskwound
Give Rabiesvaccine &
Rabies IG
Wait forthe
observation outcome
Animal ishealthy
Animaldied
Stopvaccine Continue vaccine
Animal ishealthy
Animaldied
Novaccine
Check the specimen ofanimal brain
Positive Negative
Continue vaccine Stop vaccine
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RABIES VACCINE &
IMMUNOGLOBULIN
WHO (Essen) Regimen
Day Rabies Vaccine Rabies Immunoglobulin
0 1 dose IM +
3 1 dose IM -
7 1 dose IM -
14 1 dose IM -
28 1 dose IM -
Day Rabies Vaccine Rabies Immunoglobulin
0 2 dose IM +
7 1 dose IM -
21 1 dose IM -
Zagreb Regimen
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RABIES VACCINE &
IMMUNOGLOBULIN
Rabies vaccine Purified vero cell vaccine (available in Indonesia as Verorab)Dose 0,5 mL IM on deltoideus muscle in adult or lateral thigh in children
Human diploid cell vaccine Purified chick embryo cell vaccineDose 0.5 mL IM on deltoideus muscle in adult or lateral thigh in children
Rabies ImmunoglobulinHuman rabies immunoglobulin; dose 20 IU/kg
Equine rabies immunoglobulin; dose 40 IU/kgHalf of the dose is given around the wound, and the other half is intramuscularlyinjected in different part from the vaccine.Should be given within 7 days after vaccination.
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PROGNOSIS
Wound cleansing and vaccination within a few hours after
contact with a suspect rabid animal can prevent the onset of
rabies and death.
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PROGNOSIS
Once a person exhibit signs of the disease, the person most
likely will die.
Less than 10 documented cases worldwide survive from clinicalrabies have been reported, and only 2 have not had a history of
pre- or postexposure prophylaxis.
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15-year-old girl in whom clinical rabies developed one month after she was bitten at herleft index finger by a bat. Rabies vaccine was not administered.Treatment including induction of coma with ketamine and midazolam was done, whilea native immune response matured. Ribavirin and amantadine were also added.Lumbal puncture after 8 days showed increased level of rabies antibody, and sedationwas tapered.Patient was removed from isolation after 31 days, and discharged after 76 days.After 5 months, she was alert and communicative, but with choreoathetosis,
dysarthria, and unsteady gait.
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RECOMMENDED READINGS
Rabies fact sheets. World Health Organization.http://www.who.int/mediacentre/factsheets/fs099/en/
Rabies. Centers for Disease Control and Prevention.http://www.cdc.gov/rabies/index.html
Warrell MJ. Rabies. In: Cook GC, Zumla A, eds. Mansons TropicalDiseases, 22nd ed.
Wiloughby Jr RE, Tieves KS, Hoffman GM, Ghanayem NS, Amlie-Lefond CM, Schwabe MJ, et al. Survival after treatment of rabies
with induction of coma. NEJM. 2005; 352:2508-14
http://www.who.int/mediacentre/factsheets/fs099/en/http://www.cdc.gov/rabies/index.htmlhttp://www.cdc.gov/rabies/index.htmlhttp://www.cdc.gov/rabies/index.htmlhttp://www.who.int/mediacentre/factsheets/fs099/en/http://www.who.int/mediacentre/factsheets/fs099/en/ -
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THANK YOU