Gettysburg Medical Center
 The Clinical View
 by P.E. Hoffsten, M.D.
 20 April 2005

RABIES:  KINDNESS BACKFIRED

            It seemed innocent enough.  All he wanted to do is pet the cat.  A stray cat had wandered into the 9 year old boy’s yard but every time cat was approached, it would run.  Try as he could, the boy could not catch the cat.  So his brother said to put a bowl of milk out and the cat would come to eat.  When that was done, the cat did indeed come to the bowl of milk.  The nine year old boy came up behind the cat to pick it up.  As soon as he picked up the cat, it turned around and bit him on the hand.  He dropped the cat which then ran and couldn’t be found again.  It was two days later when he is brought to the clinic because of the swelling and infection on his hand.  Dealing with any bit wound is bad enough, but the question of how to deal with rabies prevention becomes a major consideration.  The cat is no where to be found.

            The last case of reported rabies in South Dakota was in 1970.  But there were seven cases that occurred in 2004 in the United States and six of these were fatal.  The one survival was a teenage boy in Wisconsin bitten by a rabid dog.  He received a new experimental treatment and did survive.

            By far the most important step in dealing with human rabies is to prevent it.  This means not getting exposed to rabid animals.  Skunks are the most common reservoir for rabies in South Dakota.  Most people run when they see a skunk, but a rabid skunk’s behavior is unpredictable and human exposures can occur.  Not appreciated is the fact that the next most common animal positive for rabies is cattle.  Based on that alone, I am surprised that there have been no cases of human rabies in South Dakota in 35 years.  I wondered how a cattle rancher would suspect a cow had rabies, so I spoke to a veterinarian to inquire.  He said the animal becomes non-specifically ill and stops eating.  The animal tries to drink but cannot and has an abnormal bellow.  There may or may not be abnormal foaming of the mouth.  Death occurs in 7 days and the diagnosis is made by sending in the animal’s brain for examination.  The veterinarian mentioned that there are currently 6 people receiving rabies prophylaxis because of exposure to a rabid dairy cow.  The animal did have foaming of the mouth and shook saliva onto the six exposed individuals. Next in likelihood of carrying rabies are dogs and cats, rats and horses. 

            Exposure such as described in the nine year old boy above is relatively common.  If the animal can be isolated and demonstrated to be healthy for ten days under observation, no immunization is necessary.  If the animal develops illness during that time, it will need to be sacrificed and examined for the possibility of rabies.  If as in the case above, the animal cannot be isolated then rabies prevention needs to be instituted.  This consists of injections of rabies immunoglobulin to provide so called passive immunization during the incubation for rabies.  For a hundred pound nine year old boy, the cost of this was $750.00.  Then in addition, he needed to receive 5 doses of vaccine to provide adequate protection.  This cost approximately $1250.00.

            Total cost of the entire incident was around $2500.00 including antibiotics for the wound infection and tetanus immunization along with office visit costs.  During one of the visits, the father referred to his son as MDK #2.  I couldn’t figure out the abbreviation so I asked what the letters stood for.  He said that he had MDK #1 and MDK #2.  MDK#1 stood for “my dumb kid #1” and was the older son who said put the milk out for the cat.  MDK #2 was the boy who did it and was bitten.  The father said that dumb kids can really be expensive.  I thought that was kind of a harsh judgment for all that was intended was an act of kindness.

            As I indicated above, I am frankly surprised that there aren’t more problems with rabies in the United States.  This young boys hand would never have come to mother’s attention if it had not gotten infected.