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.