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.