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\begin{document}

\title{Rabies encephalitis in Mauritania}



\author[1]{Boushab Mohamed Boushab}%
\author[2]{Ahmed Benane Hacen }%
\author[3]{Baba Sidi El-Wafi }%
\author[4]{Leonardo Kishi  Basco }%
\affil[1]{Kiffa Hospital Center}%
\affil[2]{Direction des Services Vétérinaires, Ministère de l'Elevage }%
\affil[3]{Department of Medicine and Medical Specialties, Faculty of Medicine, University of Nouakchott Al Aasriya, }%
\affil[4]{Institut de Recherche pour le Developpement}%


\vspace{-1em}



  
  \date{June 14, 2024}


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\selectlanguage{english}
\begin{abstract}
From 2016 to 2021, two cases of rabies encephalitis were diagnosed and
hospitalized at the Kiffa hospital center. Neither of them had started
the rabies vaccination after the dog bites before symptoms appeared. In
countries where rabies still occurs, health workers should be trained
for an efficient management of dog.%
\end{abstract}%



\sloppy


\textbf{Rabies encephalitis in Mauritania}

Boushab Mohamed Boushab\textsuperscript{1,2}, Hacen Ahmed
Benane\textsuperscript{3}, Sidi El-Wafi Ould Baba\textsuperscript{2},
Leonardo Kishi Basco\textsuperscript{4,5}.

First name: Boushab Mohamed

Family name: Boushab

First name: Hacen

Family name: Ahmed Benane

First name:Sidi El-Wafi

Family name:Baba

First name: Leonardo

Middle Initial: K.

Family name: Basco

\textsuperscript{1}Department of Internal Medicine and Infectious
Diseases, Kiffa Regional Hospital, Assaba, Mauritania

\textsuperscript{2}Direction des Services V\selectlanguage{ngerman}étérinaires, Ministère de
l'Elevage ;Mauritania

\textsuperscript{3}Department of Medicine and Medical Specialties,
Faculty of Medicine, University of Nouakchott Al Aasriya, Nouakchott,
Mauritania

\textsuperscript{4,5}Aix-Marseille Université, Institut de Recherche
pour le Développement, Assistance Publique--Hôpitaux de Marseille,
Service de Santé des Armées, Unité Mixte de Recherche
Vecteurs--Infections Tropicales et Méditerranéennes (VITROME), Institut
Hospitalo-Universitaire--Méditerranée Infection, Marseille, France

Correspondence: Boushab Mohamed Boushab,~Department of Internal Medicine
and Infectious Diseases, Kiffa Regional Hospital, Assaba, Mauritania;
Tel: +222 46749087; E-mail: bboushab@gmail.com

\textbf{Key Clinical Message}

-The case reports remind clinicians in developing countries that rabies
is a preventable infectious disease.

-The importance of heath education on the risks of dog bite in urban and
rural communities cannot be undermined.

-Systematic and mass vaccination of dogs is one of the key intervention
measures to eliminate rabies.

-Access to post-exposure prophylaxis in health centers should be
promoted.



\textbf{Introduction}

Rabies is an acute encephalomyelitis caused by ribonucleic acid (RNA)
virus belonging to the \emph{Lyssavirus} genus,
\emph{Rhabdoviridae}family {[}1{]}. About 99\% of the transmission of
the virus to humans are due to the breach of the skin-mucosal barrier by
biting, scratching or licking infected animals, most often dogs {[}2{]}.
Human-to-human contamination is exceptional and is associated with organ
or tissue transplants from infected donors {[}3{]}. Although rabies is
an ancient zoonosis, it continues to be an important public health
problem in many developing countries {[}4{]}. Today, it is still
considered a neglected tropical disease, despite the fact that it causes
more than 59,000 human deaths each year in the world, particularly in
Asia and Africa {[}4,5{]}. Once declared clinically, it is inevitably
fatal {[}6{]}. In most of Africa, especially in West and Central African
countries, rabies notification is not mandatory, and epidemiological
data are scarce {[}7{]}. In Mauritania, enzootic rabies, which is known
to have existed for a very long time, periodically affects animals and
humans. Cases of death have been reported on several occasions. The
first reported cases occurred in 1963 in Nouakchott (Trarza region). A
man died of rabies after a cat bite in the throat, and a woman died of
rabies after a dog bite. Since then, sporadic cases of human rabies have
been reported in Mauritania in 1967, 1968, 1973-1975 and 1980 {[}8{]}.
None of these cases have been confirmed with laboratory diagnosis. These
historical data need an update. We report two cases of rabies
encephalitis occurring after being bitten by stray dogs.



\textbf{Presentation of Cases}

\textbf{Patient 1}

A 65-year-old man residing in a rural town of Tintane, southern
Mauritania, consulted at the Kiffa Hospital Center on December 2, 2018,
for hiccups and hydrophobia. Recent past history of the patient
suggested no significant medical problem, except for a scar from a bite
by a stray dog \selectlanguage{english}\selectlanguage{english}on the palm of the right hand that occurred on October
9, 2018. Immediately after the bite, the patient washed the wound with
soapy water and did not seek any medical treatment. Two months later, on
December 02, 2018, he started complaining of headache, fever, and
hiccups which required consultation at the health center of Tintane. The
symptomatic treatment he received did not have any effect on his
symptoms. Faced with the appearance of anxiety and agitation, the
patient was referred to the Kiffa Hospital Center, a regional tertiary
hospital. On admission, the patient was agitated and had hydrophobia,
pharyngeal spasms, muscle contracture, and sialorrhea since 24 hours.
The values for routine clinical laboratory tests, including hematology
and blood chemistry, were within normal range. The diagnosis of rabies
encephalitis was made on the basis of the typical clinical presentation.
A laboratory confirmation of rabies was not performed due to a lack of
technical facilities in the country. A symptomatic treatment based on
phenobarbital, diazepam, and paracetamol was administered without
success. The patient died a few hours after admission to the hospital.
The investigation around the case revealed two additional undeclared
human rabies cases in the town where the deceased patient came from,
possibly due to bites of the same rabid stray dog.

\textbf{Patient 2}

A 13-year-old boy residing in Aioun city, southern Mauritania, was
referred from Aioun hospital center on August 19, 2021, for better
management of hyperthermia and psychomotor agitation. Past medical
history indicated that a stray dog \selectlanguage{english}\selectlanguage{english}bit the patient on the left cheek
and chest three weeks earlier (July 31, 2021). On admission, a scar at
the site of the bite, restlessness, intermittent spastic hypertonia,
psychomotor agitation, persecutory delirium, fever, hydrophobia, and
excessive salivation were observed. These symptoms were reported to
occur since 36 hours prior to admission. The diagnosis of rabies
encephalitis was retained on the basis of clinical presentation.
Symptomatic treatment was administered without success. The results of
routine clinical laboratory tests were normal. The patient was
discharged against medical advice and died two days later. The
investigation around the case made it possible to find an undeclared
case in Aioun but further detailed information was not obtained.

\textbf{Case Discussion}

Rabies is one of the deadliest infectious diseases with a 100\% case
fatality rate once the signs are declared {[}9{]}. In Mauritania, rabies
has been known to exist, but reliable epidemiological data on rabies are
absent. Many cases of rabies in developing countries are not diagnosed
with laboratory confirmation and are often not even reported to health
authorities {[}10{]}. The affected subjects usually die without
appropriate care at home, without diagnosis being made. Even cases
diagnosed in hospitals are rarely reported or may be wrongly attributed
to other diseases, such as meningitis. Bite victims often do not receive
appropriate prophylactic care due to patients' ignorance, lack of
awareness among health workers, lack of necessary biological products,
or because of insufficient means to pay the cost of preventive
treatment.

In two human cases of rabies observed in our hospital, the recent
history of dog bite was the most important clue for the clinical
diagnosis. The patients consulted a medical facility only at the
appearance of the first signs of the disease when it is usually too late
for treatment to be effective. The population largely remains ignorant
of the risk of rabies in Mauritania and elsewhere {[}7{]}. In the
literature, almost all studies conducted in different parts of the world
showed that dog is the main vector in Africa, Asia, and Latin America
{[}7,9--11{]}. The incubation period observed in our two cases was 20
and 55 days, respectively. The incubation was longer in the first
patient who was bitten once on the hand. The incubation period in the
second patient, a child who was bitten on the cheek and chest, was
shorter, probably due to a larger inoculum and the site of injury in
richly innervated parts of the body near the brain.

There are a variety of non-specific prodromal symptoms of rabies,
including fever, chills, malaise, fatigue, insomnia, anorexia, headache,
anxiety, and irritability, that last up to about ten days, similar to
those of many other viral diseases {[}4{]}. The majority of patients
with rabies encephalitis develop hydrophobia, a pathognomonic sign of
rabies, as in our patients. Initially, patients experience pain in the
throat or difficulty in swallowing. Subsequently, during attempts to
swallow, they experience contractions of the diaphragm and accessory
muscles on inspiration. There may be associated features including
twitching of neck muscle, vomiting, cough, grimacing, and seizures.

There is no effective treatment for rabies. Few patients survived after
intensive care {[}5{]}. An improved surveillance, anti-rabies
vaccination of dogs, and access to post-exposure prophylaxis are
required to reduce the risk of rabies and eliminate this disease
{[}12--14{]}. In our two patients, the post-exposure vaccination was not
administered due to ignorance of the risk of rabies and because
anti-rabies vaccination is generally not accessible. In addition to
vaccination, an urgent administration of first aid immediately after
exposure is essential.

\textbf{Transparency Declaration}

The authors have no conflicts of interest to declare.

\textbf{Author contributions:}

Boushab Mohamed Boushab (bboushab@gmail.com) :1st author and
Corresponding author, he has been involved in drafting the manuscript,
made substantial contributions to study conception and design, clinical
data verification, discussion section. Hacen Ahmed Benane
(ahmedbenane@gmail.com) : 2nd author, manuscript correction. Sidi
El-Wafi Baba:( drsiwamed@gmail.com) 3th author, manuscript correction.
Basco Leonardo Kishi (lkbasco@yahoo.fr) : 4th author, manuscript
correction. All authors have read and approved the final manuscript.

All authors have read and approved the final manuscript.

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