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 ​​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.