A 22-year-old woman comes to the emergency department for evaluation of a bite on her right arm by her neighbors' dog. The neighbors accompany the patient with their dog, which is not immunized against rabies but appears healthy. The patient has no other medical conditions and takes no medications. Her last tetanus booster was 3 years ago. Temperature is 37 C (98.6 F), blood pressure is 110/70 mm Hg, pulse is 76/min, and respirations are 12/min. On her right forearm is a shallow bite wound that is 1 cm long with no erythema or purulent drainage. The wound is cleaned with soap, water, and povidone-iodine solution. Which of the following is the most appropriate next step in management of this patient?

Question

A 22-year-old woman comes to the emergency department for evaluation of a bite on her right arm by her neighbors' dog.  The neighbors accompany the patient with their dog, which is not immunized against rabies but appears healthy.  The patient has no other medical conditions and takes no medications.  Her last tetanus booster was 3 years ago.  Temperature is 37 C (98.6 F), blood pressure is 110/70 mm Hg, pulse is 76/min, and respirations are 12/min.  On her right forearm is a shallow bite wound that is 1 cm long with no erythema or purulent drainage.  The wound is cleaned with soap, water, and povidone-iodine solution.  Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec25c8_d469_e866_bc81_53eb4021a6cf_MD0003_00 Rabies usually presents with motor weakness, paresthesias, and encephalitis that progress to coma and death. Rabies is transmitted following a bite from an infected mammal. In developing countries, dogs account for >90% of transmission due to inadequate rabies control programs. In contrast, rabies in domesticated animals is very rare in the United States due to effective rabies vaccination. Most cases of rabies in the United States are due to bites from wild animals (eg, bats, raccoons, foxes, skunks). Postexposure prophylaxis (PEP) consists of a series of rabies immunizations as well as rabies immune globulin. However, not all patients require PEP: Patients exposed to high-risk wild animals (eg, bats, raccoons, foxes, skunks) should receive PEP for rabies if the animal is unavailable for testing. In particular, bat bites can go unrecognized, so PEP is recommended following direct exposure to bats (unless the patient is constantly aware of the bats and is certain a bite was not inflicted). In the rare situation that the high-risk wild animal is available for testing, PEP can be withheld until the animal is euthanized, its brain has been tested for rabies, and the test results are available. Patients bitten by domestic animals (ie, pets) in the United States do not require PEP if the pet is available for testing. The incubation period for rabies is usually 1-3 months, but animals that are contagious (ie, have rabies virus in their saliva) will be symptomatic 5-10 days after becoming contagious. Therefore, pets available for quarantine can be observed for 10 days for signs of rabies. However, if the pet is unavailable for quarantine (or is symptomatic), PEP should be administered. Patients bitten by low-risk animals (eg, squirrels, chipmunks) do not need PEP. (Choices A and B) If the dog is available, it can be observed for 10 days for signs of rabies. There is no need to euthanize it for testing. (Choice D) PEP is painful, costly, and intense (4 visits). Rabies incubation lasts several months and PEP is effective at any point during that time; therefore, immediate PEP is not indicated when the animal is available for observation or testing. (Choice E) Patients with bites from high-risk wild animals or symptomatic domestic animals (eg, dogs) should start PEP if the animal is unavailable. However, if the animal is available, either observation (pets) or testing (wild animals) should be performed before deciding on PEP. Educational objective: Rabies postexposure prophylaxis (PEP) for mammalian bites includes rabies vaccine and rabies immune globulin. PEP is indicated when the animal is unavailable or symptomatic. Available, asymptomatic animals can either be observed (pets, for 10 days) or tested (wild animals) to determine the need for PEP. References: Use of a reduced (4-dose) vaccine schedule for postexposure prophylaxis to prevent human rabies: recommendations of the Advisory Committee on Immunization Practices. (http://www.ncbi.nlm.nih.gov/pubmed/20300058) Rabies: rare human infection - common questions. (http://www.ncbi.nlm.nih.gov/pubmed/26384549)

A 22-Year-Old Woman Comes to the Emergency Department for Evaluation