1.
EM R3 김현진

2. PATHOLOGY-Virology- Neurotropic virus of genus Lyssavirus.
The classic rabies virus, two European bat lyssaviruses, an Australian bat lyssavirus, African Duvenhage virus
Produce fatal encephalomyelitis in humans

3. Transmission
Infection initially of wild and then domestic animals-> humans by bites, aerosol inhalation in bat caves
Most infections (90%) are transmitted via domestic animals (cats and dogs)
Scratches infected with saliva

4. Transmission Human to human transmission has not been recorded,
Exception of six cases resulting from corneal graft
Breast milk
may be shed
Transplacental infection
Occurs in animals but has not been reported in humans.

5. Pathophysiology Virus replicates in muscle cells(bite site)
Ascends to central nervous system via the peripheral nerves.
Central nervous system,
Massive viral replication on membranes within neurones
Transmitted directly across synapses into efferent nerves
Deposited in almost every body tissue
Incubation period from bite to disease
Usually between 30 and 90 days.
Bites on the head and neck have a shorter
Sometimes even as short as 15 days

6. Pathology Brain, spinal cord, and peripheral nerves Inflammation
Ganglion cell degeneration
Perineural and perivascular mononuclear cell infiltration
Inflammation
Midbrain and medulla in furious rabies
spinal cord in paralytic rabies
Vascular lesions
Thrombosis and haemorrhage
Brainstem, hypothalamus, limbic system
Focal degeneration
Salivary, lachrymal glands, pancreas, adrenal medullae

7. SYMPTOMS AND SIGNS First symptom Prodromal symptoms
Itching, pain, or paraesthesia at site of healed bite wound
Prodromal symptoms
Fevers, myalgia, headache, irritability, depression, and upper airway or gastrointestinal symptoms

8. Furious rabies More common
Irritability, agitation, and hyperaesthesia.
Autonomic disturbances (disorders of blood pressure, hypersalivation, and sweating).
Symptom of hydrophobia
Inspiratory muscle spasm
Painful laryngospasm
Terror (fear of swallowing)
Fatal within months
Very few reported cases of survival

9. Paralytic rabies Under 20% of human cases Bites from vampire bats
Bites in people who have received pre-exposure vaccination.
Flaccid paralysis
Bitten limb
Ascends (symmetrically or asymmetrically) with pain and fasciculation in the affected muscles.
Mild sensory disturbance
Fatal paralysis of respiratory muscles
Hydrophobia is rare
A few spasms of the laryngeal muscles
Survive for up to 30 days without ITU support

11. DIAGNOSIS-Laboratory diagnosis-
Animal
Brain biopsy
Rabies antigen by direct immunofluorescence or PCR
Observed for a period of 10 days
Not overtly ‘‘rabid’’
Any sign of infection or deterioration, brain tested
Patient suspected rabies
Viral RNA by PCR or viral antigen in skin biopsies
Earliest diagnosis
Rabies antibodies in CSF or serum
Not usually detectable until the eighth day
Most cases died before an antibody response is detectable.

12. RISK ASSESSMENT Circumstances of the bite
Biting animal’s behaviour
Provoked or unprovoked
Wild or pet animal,
Site of bite
Initial treatment of wound
Previous vaccination of the patient and animal
Country in which the bite

13. RISK ASSESSMENT Type of exposure
Bites pose a high risk
Scratches and non-bite exposure of open wound or mucous membrane assumed to risk.
Contact with animal’s coat or faeces
Not risk
Position of the wound
Face and neck should be treated as more serious

14. TREATMENT Prevent development of rabies
Once rabies symptoms have developed, treatment itself is manily supportive.
Cleaning of the wound and use of post-exposure prophylaxis
Most important steps
Reduce risk from a known rabid animal bite from 37–60% to near zero.
Supportive care
Control their pain and terror.
Paralysis, sedation, and ventilation.
Antiserum, antiviral agents, interferon, corticosteroids
Useless

15. Pre-exposure vaccination
Not aim to provide full immunity
Deltoid on days 0, 3, and 28
Seroconversion rate
98.2%.
Boosters
Between 6 and 24 months

16. Wound treatment Easily killed by sunlight, soap, and drying
Almost completely prevented by local wound treatment given within the first 3 hours after exposure
Iodine solution, 40–70% alcohol, or quaternary ammonium compounds

17. Post-exposure prophylaxis

18. Passive immunisation Human rabies immunoglobulin (HRIG)
Neutralizing the rabies virus
Enhance patient’s T cell response to the vaccine
Dose
20 IU/kg body weight
Infiltrated around wound site as much as is anatomically
Hypersensitivity reactions
1 - 6%.

19. Vaccination Protocol Complication Vaccinated patients
booster vaccine on days 0 and 3
Unvaccinated patients
0, 3, 7, 14 and 28 days
Complication
Pain, swelling, erythema, and itching around the injection site
30–74%
Anaphylaxis rates
0.1%.

20. Vaccination Pregnancy
not a contraindication vaccine or immunoglobulin,

22. 광견병,대한의사협회지 제42권 제7호

23. 캄랍주(공수병 사람 면역글로불린 )

24. 캄랍주(공수병 사람 면역글로불린 )