Two hours later the boy became irritable and agitated, refusing food & drinks, they said. I asked whether there was a history of vomiting or headache to exclude meningitis, but the answer was no. During discussion, I noticed that the boy was scared, hugging his father, with his own neck fully flexed with no agitation nor irritability. When I asked to examine him, the boy started to scream & became very aggressive & agitated, biting everyone & spitting everywhere with abnormal behavior & fine tremors in the hands. I auscultated the chest & heart & both were free apart from tachycardia. Temperature was 38C. There was aerophobia and inability to drink water even after the agitation episode.
I asked for history of animal bites or scratches even if it had happened a long time ago; the answer was they were not sure. I admitted the patient under the supervision of my consultant who advised to give midazolam 3mg IM as the patient was too much agitated & aggressive to insert IV line to make the boy calm & reevaluate. Our provisional diagnosis was rabies.
The boy did not sleep the whole night as I went to reevaluate him at 4 am, 6 am & 8 am. He was becoming more irritable & more aggressive. At 9 am, the consultant advised neurological & pediatric consultations who both suspected rabies as a provisional diagnosis. MRI brain, LP, CBC & full chemistry were requested, but none of them was done due to the agitation & aggressiveness of the boy. The boy arrested. CPR was done for 30 minutes but unfortunately he passed away on Thursday at 5 am. Waleed M. K. Abu Zaid, Resident of Infectious Diseases, Al Gharbia, Egypt.
Later author comment:
Thanks for your participation & knowledge sharing
3 days ago we came to know that there is a history of dog bite since September 2017 through an investigation team from the directorate.
Relatives were not telling us the truth though we asked them more than 10 times
So, based on the new information, rabies is the first possibility
According to the MOH case definition, this is a probable case.
Another physician commented:
I've seen rabies in TX in the 1980's.. 12 yo asian f presented with a very sore throat and fever. She had no history of exposure to animals or animal bites. She had not traveled to endemic areas. She was alert, but appeared very ill. On exam, had autonomic instability (her blood pressure fluctuated wildly with something like stroking her arm) and a Haman's crunch. Diagnosis was difficult as she had things like a pneumomediastium. By the following morning, she could not handle her secretions and became obtunded. She was combative during intubation, Rabies; indeed it was her Cambodian refugee parents that raised the diagnosis! Dx at brain biopsy showed rabies, but PCR (by CDC) said US rabies strain, not SE Asian one. A course of Ribavirin (then in development) appeared to slow her progression, but she died.