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LETTER TO EDITOR
Year : 2004  |  Volume : 52  |  Issue : 1  |  Page : 132-133

Diagnostic dilemma in flaccid paralysis following anti-rabies vaccine


Department of Neurology, Neurosciences Center, All India Institute of Medical Sciences, New Delhi - 110029

Correspondence Address:
Department of Neurology, Neurosciences Center, All India Institute of Medical Sciences, New Delhi - 110029
madhuribehari@hotmail.com



How to cite this article:
Srivastava A K, Sardana V, Prasad K, Behari M. Diagnostic dilemma in flaccid paralysis following anti-rabies vaccine. Neurol India 2004;52:132-3


How to cite this URL:
Srivastava A K, Sardana V, Prasad K, Behari M. Diagnostic dilemma in flaccid paralysis following anti-rabies vaccine. Neurol India [serial online] 2004 [cited 2014 Apr 18];52:132-3. Available from: http://www.neurologyindia.com/text.asp?2004/52/1/132/6733


Sir
Serious neuro-paralytic complications occasionally follow immunization with neural tissue vaccine. The reported incidence of such a complication is 1:220 to 1:12000 vaccines.[1] Patients who receive anti-rabies vaccine (ARV) as post-exposure prophylaxis following a dog bite or exposure to a rabid dog occasionally develop flaccid paralysis. We describe a patient who developed flaccid paralysis following exposure to ARV.
A 24-year-old man was admitted with complaints of tingling sensation in the distal parts of all four limbs for 5 days, difficulty in walking for 4 days, difficulty in lifting his arms above the shoulder for 2 days and inability to close his eyes and whistle, nasal twang of voice and nasal regurgitation for 1 day. His unvaccinated pet dog developed rabies and had died one month ago. Following this the whole family was vaccinated with Semple type ARV. The patient received 11 injections on alternate days till 10 days before onset of symptoms. A day after the last injection he developed dull continuous frontal headache along with corrhyza, which improved completely in 3 days without treatment.
On examination he was found to have bilateral lower motor neuron (LMN) type facial nerve weakness, decreased palatal movement, with central uvula and decreased gag reflex. There was weakness of neck flexors and proximal limb muscles, absent deep tendon reflexes (DTR) with flexor plantar response. Cerebrospinal fluid study revealed no cells, 83mg/dl protein, sugar 97mg/dl (simultaneous blood sugar 120mg/dl) and globulin positive. Magnetic resonance imaging (MRI) of the brain and cervical spine were normal. Motor nerve conduction studies showed decreased conduction with dispersion of compound muscle action potential, low amplitude with prolonged distal latency and decreased nerve conduction velocity. Sensory conduction was normal. Serological examination for HIV was negative. Corneal smear for rabies was negative. After hospitalization, the patient was placed on steroids for two weeks. Limb power returned to normal in 3-4 days. Nasal regurgitation and nasal twang of the voice improved in 4-5 days. Right facial weakness and absent DTR were present at 3 months follow-up. At 6 months follow-up, facial weakness improved almost completely, though reflexes were still absent.
A neuro-paralytic syndrome after Pasteur's post-exposure rabies immunization was first recognized in 1889. Although safer vaccines have been developed, Semple vaccine is still used commonly because of its low cost and easy availability. Semple vaccine is a suspension of phenol or beta- propionolactone killed virus in sheep brain. [2] The incidence of a neurological complication with Semple vaccine is approximately 1 per 220.[2],[3] Reported reactions have included encephalomyelitis, transverse myelitis, acute polyradiculoneuropathy and peripheral and cranial neuropathy.[2],[4]
Measurement of rabies antibody titer in the serum and cerebrospinal fluid could be of help to differentiate between paralytic rabies and sporadic GB syndrome.[5] In India a serious look into the matter is required as 25,000 people fall victim to rabies every year and about half a million people receive anti-rabies vaccine as post-exposure prophylaxis after being bitten by a rabid animal.[1] 

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1.Dutta TK. Rabies in endemic countries. BMJ 1994; 308; 489: 488-489.  Back to cited text no. 1    
2.Swamy HS, Anisya V, et al. Neurological complications due to semple type anti rabies vaccine. JAPI 1991;9:667-9.  Back to cited text no. 2    
3.Courrier A, Stenbach G, Simonnet P, et al. Peripheral neuropathy following fetal bovine cell rabies vaccine. Lancet 1986;1:11273.  Back to cited text no. 3    
4.Appelbaum E, Greenberg M, Nelson J. Neurological complications following antirabies vaccination. JAMA 1953;151:188-91.  Back to cited text no. 4    
5.Hemachudha T, Griffin DE, et al. Myelin basic protein as an enccphalitogen in enccphalomyclitis and polyneuritis following rabies vaccination. NEJM 1987;316:369-74.   Back to cited text no. 5    

 

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