Encephalitis following Purified Chick-Embryo Cell Anti-Rabies Vaccination

Transcription

1 CASE REPORT JIACM 2003; 4(3): Encephalitis following Purified Chick-Embryo Cell Anti-Rabies Vaccination NS Neki*, Ashok Khurana**, Ashok Duggal*** Abstract A case of encephalitis following purified chick-embryo cell rabies vaccination (Rabipur) is reported because of its rare occurrence. Introduction Encephalitis occurs due to a variety of causes including vaccination. It presents clinically as fever, malaise, headache, vomiting, signs of behavioural and speech disturbances, alteration of consciousness, epileptic seizures, and focal neurological signs like hemiparesis, cerebellar involvement, sensory loss, and spasticity. But encephalitis due to rabipur vaccination is extremely rare. Hence, we are reporting the case. Case report A 32 years old man presented with history of dog bite 1 month back for which he was vaccinated with Rabipur as per schedule (0, 3, 7, 14, 30). On the day after the fifth dose of the vaccine, he started having high grade fever with chills and rigors. After 3 days, he developed difficulty in opening the right eye, as well as inability to walk. There was swaying more towards left side. There was no history of headache, vomiting, bowel/bladder disturbance, or deviation of angle of mouth. examination revealed grade IV lower shade power on right side and grade IV upper shade on left side. All the deep tendon reflexes were brisk with absent abdominal reflexes and bilateral plantar flexor response. There was no sensory loss. Severe truncal ataxia and head nodding was present. Bilateral cerebellar signs were present more so on left side. There were no signs of meningeal irritation. Skull and spine examinations were unremarkable. Investigations revealed Hb 11.5 gm%, TLC 11,500/mm 3, DLC P 80, L 19, M 1, E 0, blood urea mg/dl, serum creatinine 0.81 mg/dl, fasting blood sugar 96 mg/dl. The peripheral blood film for malarial parasite was negative and Widal test was also negative. CSF examination revealed 1-4 leucocytes mainly lymphocytes, Proteins 112 mg/dl, globulins positive, glucose 96 mg/dl (corresponding random blood sugar On examination, he was febrile, pulse rate 102/min, BP 130/80 mmhg, temperature 101 F, respiratory rate 22/ min. Higher functions were normal. Cranial nerve examination showed partial right third nerve palsy in the form of ptosis and mildly-dilated non-reacting pupil on the right side. There was bilateral sixth nerve palsy with horizontal nystagmus in both eyes (fig. 1). Other cranial nerves were normal. Next day, the patient developed right medial rectus palsy too. Fundus examination was normal. Motor Fig. 1 * Associate Professor, ** Senior Lecturer, *** Senior Resident, Department of Medicine, Guru Nanak Dev Hospital/Govt. Medical College, Amritsar (Punjab). Contd. on page 258

2

3

4

5

6

7

8 Contd. from page 251 Fig mg/dl). MRI 3-D brain showed hyperintensity lesions in the brain stem and basal ganglia suggestive of encephalitis (fig. 2). Treatment was given in the form of antibiotics, cerebral decongestants, steroids, and proton-pump inhibitors. The latter two continued for 1 month. On regular follow up for 1 month, our patient showed improvement. Nystagmus disappeared, and also, bilateral lateral rectus and right medial rectus palsies recovered. Patient was able to walk on his own without support, with improvement of ataxia to the extent of 95%. Discussion Encephalitis inflammation of the brain substance, is usually acute in onset and occurs due to a variety of causes, 258 Journal, Indian Academy of Clinical Medicine Vol. 4, No. 3 July-September 2003

9 most commonly viral in origin 1,2. But, encephalitis following purified chick-embryo cell rabies vaccination (Rabipur) is very rare. Rabipur, a 2nd generation anti-rabies vaccine contains inactivated rabies virus propagated in chick-embryo fibroblast cell cultures. It is given in 5 doses (0, 3, 7, 14, 30 days) for post-exposure prophylaxis 3. Since this vaccine lacks nervous tissue, incidence of neurological complications are rare; and only isolated cases have been reported 3,4,5. The extensive review of the literature revealed that the case reported by Bruns et al 4 had high fever and vomiting suspected to be encephalitis after simultaneous vaccination with Rabipur/Berirab with no neurological deficits. On the other hand, Chakravarty A 5 described a case of Guillain-Barre syndrome following Rabipur postexposure prophylaxis. But our patient had involvement of cranial nerves as well as cerebellum. Anti-cardiolipin antibodies (ACA) are found in 24% patients with rabies vaccination induced neurological complications, but their pathogenic role is unclear 6. High titres of IgG and IgM antibodies to GM 1, or GD 19 gangliosides play a pathogenic role in demyelinating inflammatory processes characteristic of rabies vaccine induced acute neurological complications 7. No correlation between antibody to myelin basic protein for the development of neurological complications after rabies vaccine could be found 8. References 1. Milne Anderson. Virus infections of the nervous system. Brain s Diseases of The Nervous System. 10th edition, Oxford University, 2000; Bharucha NE. Viral infections of the central nervous system. API Text Book of Medicine, Sixth Edition, 1999; p Vadopija I, Baklaic F, Vadopija R. Rabipur, a reliable vaccine for rabies protection. Vaccine 1999; 17 (13-14): Bruns R, Wiersibitzky S, Weisev, Burtzlaff C. High fever and vomiting (suspected encephalitis) after simultaneous vaccination with Rabipur/Berirab Kinderarztl Prax 1993; 61 (9): Chakravarthy A. Neurologic illness following post-exposure prophylaxis with purified chick-embryo cell antirabies vaccine. J Assoc Phy India 2001; 49: Chaleomchan W, Hemachadha T, Sakulramrung R, Deesomchok U. Anticardiolipin antibodies in patients with rabies vaccination induced neurological complications and other neurological disease. J Neurol Sci 1990; 96 (2-3): Laouini D, Kennou MP, Khoufi S, Dellagi K. Antibodies to human myelin proteins and gangliosides in patients with acute neuroparalytic accidents induced by brain derived rabies vaccine. J Neuroimmunol 1998; 91 (1-2): Ubol S, Hemachudha T, Whitaker JN, Griffin DE. Antibodies to peptides of human myelin basic protein in post-rabies vaccine encephalomyelitis sera. J Neuroimmunol 1990; 2 (2): Journal, Indian Academy of Clinical Medicine Vol. 4, No. 3 July-September