Fatal Rabies Case Did not Die “Accidentally” and Should not Be Considered a Rabies Survivor

To the Editors: Caicedo et al1 reported about a 9-year-old girl who developed rabies in Colombia. She improved to the extent that she was discharged from the intensive care unit (ICU) on hospital day (HD) 66. On HD70, she had dyspnea, fever, hypoxemia and purulent sputum. Chest radiograph showed a new focal infiltrate. She was readmitted to ICU and given antibiotics. Over the next 4 days in ICU, she had a complicated course, including metabolic disturbances and progressive respiratory failure leading to intubation and mechanical ventilation. On HD74, she developed shock with evidence of myocardial dysfunction. During management of her shock, she had attempts at placing central venous catheters causing bilateral pneumothoraces. She died on HD75 with refractory hypotension. It is incorrect to suggest that this death was unrelated to rabies by stating that she “died accidentally during convalescence.” There was nothing accidental about her death. Even if she was virologically cured, her death was still an indirect consequence of rabies. Specifically, it was because of complications of her critical illness due to rabies. Many deaths among patients who survive the first few days in an ICU are not from what put them there in the first place, but instead result from complications including nosocomial infections, hemorrhage or iatrogenic complications. In this case, the nosocomial event that led her ICU admission, intubation and subsequent shock was likely hospital-acquired pneumonia, which is the second commonest nosocomial infection.2 Both nosocomial pneumonia and iatrogenic pneumothorax are hospital-acquired adverse events associated with high mortality.3 There is no doubt that if she had not acquired rabies, she would not have developed these complications and died. The final documented examination on HD55 indicated that although she was awake, had spontaneous movements and was breathing without mechanical support, she had severe neurological sequelae of rabies, including ophthalmoplegia and encephalopathy that rendered her unable to consistently follow commands. It is unknown if clinically significant neurological recovery would have occurred had she lived. We believe it is incorrect to consider this patient to be a survivor from rabies. Although the report indicates “whether to call our patient a survivor is debatable,” the senior author did not show her death on the cited survival curves (http://mcw.edu/rabies, accessed November 25, 2014). The survival curves are titled “Rabies survivors: n = 5, index survivor excluded,” which includes 2 patients who have died and also another patient who did not develop neutralizing antirabies virus antibodies and probably did not have rabies at all.4 The remaining 2 survivors from Brazil and Qatar received vaccine before the onset of their disease,1 similar to other survivors who did not receive the Milwaukee protocol.5 We are concerned that inappropriately designating survivorship has played a role in promoting use of the Milwaukee protocol and delayed progress toward developing effective therapies for human rabies. The lack of efficacy and serious concerns about the Milwaukee protocol have recently been summarized in detail in a recent review authored by one of us (A.C.J.).5 A discussion of these concerns is beyond the scope of this letter. Alan C. Jackson, MD Department of Internal Medicine (Neurology) University of Manitoba Winnipeg, Manitoba, Canada Department of Medical Microbiology University of Manitoba Winnipeg, Manitoba, Canada Allan Garland, MD, MA Department of Internal Medicine (Critical Care Medicine, Respiratory Medicine) University of Manitoba Winnipeg, Manitoba, Canada Department of Community Health Sciences University of Manitoba Winnipeg, Manitoba, Canada

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