Rabies Scare

[jeebusjones]

I should stress that her symptoms are unlikely to be manufactured due to stress; she is not worried about rabies at all, since she believes the vaccine alone, started four weeks ago, should have been 100% effective.

[FBN]

He suggested we get tested (there is a non-invasive test to confirm, apparently), but we were too afraid to do so.

Apologies if I seem a bit blunt but you were offered a solution here; doing the test is not going to change the odds of having contracted rabies but will confirm or exclude the diagnosis.. I really can not see an alternative course of action here..

Have it done and deal with it if it is confirmed; it is not the end of the world. If it is not, then put this behind and move on..

[jeebusjones]

It would be the end of her world and possibly mine - if she has it there's a fair chance I do, too. The doctor seemed to think her symptoms were not indicative of rabies, but given the non-specific nature of symptoms of the prodromal stage, his assessment wasn't very reassuring.

I guess I'll see how we feel tomorrow.

[FBN]

Can only wish you the very best of luck and support!!

Your chances of having rabies is small; nobody here on this forum can get closer to it than that.

Your girlfriend very likely has another underlying condition which could (and need) be imminently treatable; don't delay getting her sorted with a proper diagnosis and treatment.

Hopefully by tomorrow, you will read this thread again, rid finally of all your anxiety!!

[Louie77]

In my opinion, you should have the test done. It's better to be prepared than just sit around and wait.

Good luck!

[jeebusjones]

Well I'm afraid it looks almost certain that I have rabies. The girlfriend seems in the clear, but not me. This is not a joke. This is real.

At the time of our exposure, I had the remnants of a burn wound on my index finger. It was perhaps one week old, but I had just peeled the dead skin off, revealing the tender, as yet not fully healed skin below. At the time I wasn't worried about it, because I mistakenly thought the virus needed access to the bloodstream. Not so. It merely needs access to the nerves, and a second degree burn does not adequately cover the nerves for 2-3 weeks afterwards.

So all the virus-laden saliva was all over the exposed nerves of the second layer of skin.

For days now, I've been having the most severe headaches of my life. Never before have I experienced anything like this. At first I attributed it to stress and my newfound valium addiction. However, the headaches have become steadily worse, and are to the point that now I can't even sleep at night.

Combined with this is the disturbing fact that the site of the old burn wound is now tingling/itching, ALL THE TIME. It won't stop. This is, almost without a doubt, rabies.

There are two options here: I'm having a nervous breakdown and manufacturing all of these incredible real-feeling symptoms, or I have rabies.

If I last the night, I'll be heading to the doctor's tomorrow. But I fear the worst.

What do you guys think?

[FBN]

Please seek appropriate medical attention at a proper medical facility such as Chula or one of the large private hospitals where infectious diseases are managed. Even if you have rabies, some measures may still be available to you but they have to be instituted asap..

It does not seem that you have been tested yet. Get it done asap!

[Louie77]

Or contact your embassy, they can refer you to someone and know what to do in these situations.

[jeebusjones]

I'm in Singapore now, I arrived here yesterday. I wanted to be close to my parents (who live there), and also have access to a better medical system.

I went to a hospital this morning which supposedly specializes in communicable diseases. I was told that this particular hospital had the means to test for rabies, but this being Chinese New Year that particular clinic was closed.

I did have a long talk with one of the doctors. He agreed there was a significant risk but tried to reassure me that my symptoms are more likely due to lack of sleep and intense stress. He prescribed some pain meds, but in spite of taking them the headache remains just as severe.

Thing is, this morning, while talking to the doctor, the headache had pretty much subsided. It wasn't until I arrived home, early afternoon, that it returned with a vengeance.

I have a history of anxiety attacks so it's becoming difficult to know what are genuine symptoms and what are manufactured, but this headache is unlike anything I've ever experienced. The itching/tingling sensation in my finger comes and goes -- sometimes I feel it, sometimes I don't.

The doctor said if the feeling spreads, or if I feel pain shooting up my arm, then I should be more concerned. He thought this particular tingling/itching might be due to my extreme paranoia and overactive imagination, but I'm not so sure. It's true that I didn't feel it at all immediately after the visit, so perhaps my mind is playing a role here.

But it's the headache that's really getting me, because it is real. Has anyone heard of such an intense, steady headache, encompassing the entire head at times and specific parts at other, being caused by stress/lack of sleep?

I really fear the worst.

[jeebusjones]

Oh and FBN, I presume you are referring to the Milwaukee Protocol. According to the CDC I wouldn't be an eligible candidate, because I received the final vaccine booster after these symptoms had started (the headaches).

Also, the Milwaukee Protocol is inconsistent and as yet unproven -- there have been only 4 documented survivals so far. And anyway, Singapore being a rabies-free country I'm not sure they'd have the docs and equipment available to attempt it.

[FBN]

Not talking about protocols yet; you need to get tested.

Your headaches can not be due to rabies; too early..

Try NUH in Singapore; they have an ER and should be able to do the test even during holidays; Singapore has probably the best medical care in the region so make use of it..

[jeebusjones]

Thanks FBN. But I'm not sure you can say it's too early for the headaches to be caused rabies. The median incubation period in the United States is 36 days -- I'm at about 34 days post-exposure at the moment.

I had 1 g of paracetamol earlier this afternoon which didn't help at all. But after having 500 mg more about an hour ago, followed by a beer, the headache has largely subsided.

If the headache were caused by rabies, would the pain ease with simple alcohol and paracetamol?

I'm hoping if I can just get a good night's sleep it will go away. I haven't been sleeping much at all these last couple of weeks. And when I woke up this morning, in spite of having only a few hours' sleep, the headache was not present, so, hopefully, that's all it is. I just don't know, but it's absolutely terrifying.

[jeebusjones]

After taking quite a bit of pain meds and getting some rest, the headache seems to have subsided.

But FBN, I'm curious about the measures that you mentioned might be available. I've read somewhere that amputating the infected limb can stop the progression of rabies.

When is it too late to do so? If a person is already experiencing symptoms such as tingling/itching at the site, and headaches, is it too late for amputation to be effective?

[FBN]

Amputating a limb is not an option.

Treatment options in confirmed rabies would be supportive and symptomatic depening on clinical signs and symptoms at the time of presentation and progress. We are talking here of management in an ICU or high care environment.

There are documented survival cases with this management.

Your approach to this so far is not supported by even the flimsiest of physical evidence from the cat to where we are now so I think, in order to keep a realistic approach to this event, we have to keep that in mind. You have done your research, which is quite appropriate, but opted for the worst case scenario in each aspect of the evolvement of this disease noted in research material from incubation periods (which can be months to years) to symptoms which are absolutely non-specific till terminal disease. The incubation periods you have deemed relevant to you are actually related to massive bytes and huge viral loads in the facial or head and neck area by an animal that is secreting maximal viral loads.

Your anxiety has taken you to a level where anything that happens now to your health now, perhaps even symptoms that you would have probably completely ignored at other times, is considered to be rabies.

So, the concern that you have for having this, is perfectly understandable but try and just consider for a moment that you do NOT have rabies.

Anxiety is a viscious circle and one can lose perspective quite easily and where you are going now, is not sustainable. How long can you carry on like this? How long will each and every headache or fever you get mean rabies? Once you are past the deadline incubation period of 38 days you have set for yourself, will you be assured that you don't have rabies? What happens if you do get a fever and headache on day 40, or 60?

Get tested. If the worst case scenario is the one you have to deal with, do it with a belief that you WILL be a survivor; you have had the PEP in good time according to a proper protocol; this is the ONLY fact that is valid at this point, work from there...

Good Luck!

[jsflynn603]

Short post because the system just ate my long post.

The likelihood of you your girlfriend having is probably less than one in 10,000. Occams razor would suggest that the cat died from poisoning.

The Red Cross worker's statement is ludicrous.

Years 2002-2003, greater Bkk rabies rate amongst strays were about 1:3300 dog, not half!

70% of confirmed rabies cases in Bkk have been from dogs. I'd suspect, but am not sure that the bulk of the rest were rat and or bat related and that very few if any were cat related.

I can't rewrite what I wrote just now but will later today and edit this so substantiate.

[jsflynn603]

Since I don't seem able to edit my former post, here is the re-created version:

First I'd like to say that the person from the Red Cross who told you that 50% of stray dogs are rabid in Thailand should be fired on the spot. The Red Cross does not tolerate such mis-information, especially on such a "hot" topic. I suggest that you get in touch with the Director about that.

50% of stray dogs in Bangkok being rabid is a ludicrous statement. The last study of stray dogs from Bangkok available appears to be my reference #1. This study indicates that 1:3314 of Bangkok stray dogs were rabid. That is three hundredths of one percent, a far cry from 50%. If 50% of stray dogs were rabid in Bangkok it would be made into a horror film. One out of 3000 is far, far less than 1500 out of 3000.

From #1: (See farther down to find the document)

"All dogs tested were strays. Of these, 1425 dogs were male (43%), 1866 dogs were female (56%) and in 23 dogs sex was not recorded (1%). Estimated ages of dogs ranged from 1 month to >8 years.

The saliva of a 2-year-old female dog was found positive by both LAT and RT-PCR, as revealed by the appearance of a 524 base-pair fragment of rabies virus N gene. Saliva samples from dogs which previously known to be positive or negative for rabies virus infection were used as controls (Fig. 1). The prevalence of rabies virus infection among stray dog investigated was 0.03% (1 of 3314 dogs)."

I have read that (depending on where you look) ~70% of confirmed human rabies cases came from dogs in Thailand but also Rabnet (WHO) shows confirmed dog related cases for "latest data, probably 2003" to stand at ~87% dog and 12.5% other domestic animal. Cats would be present in that group. Contrary to my (and probably popular belief) bats have not (outside of caving incidents) been a real problem in Thailand (though ~8% purportedly are rabid (bats, not the cavers), nor has other wild animals including rats, though I was surprised to see that two squirrels were tested positive (America has a history of zero rabid squirrels). Domestic cattle including water buffalo have been tested positive, assumed to be caused by a dog bite.

1. To find my source use as search keywords: "Prevalence of rabies virus infection and rabies antibody in stray dogs: A survey in Bangkok,Thailand" Google has full text, avoid Elselvier or Science Direct (they charge). This source also has a map of Bangkok, some areas show very high seropositivity (dogs are protected against rabies) if you lie within one of these areas that makes transmission to the cat even less likely. As one moves out of urban Bkk, the level of dog seropositivity drops to below 50% (and thus poses a rising risk to humans.) WHO recommends that a 70%+ seropositivity rate be maintained, below this rabies will spread, theoretically above this, a sort of "steady state" is maintained. Outside the central area of Bkk the level of seropositivity drops to about 50% meaning that ½ of the dogs are not protected against rabies (possibly the statistic that the Red Cross person was trying to convey?). Not protected against rabies does not mean that they are rabid. A bite from a dog with inadequate seropositivity will only infect you if the dog is also rabies infected, mere inadequate seropositivity does not make said dog infective.

If only one in 3314 strays collected in Bkk in 2002-2003 were rabid and cats represent ~13-30% of all cases that makes the likelihood of the cat being rabid low, but not impossible. Add to this that the cat never exhibited aggressive behavior (stick a pill in my mouth and I'll bite) an important symptom. Add to this that the "bite" may not have been a "bite." Septicemia from the infected wound or poisoning and other causes can cause such symptoms. White foam is more indicative of rabies than yellow (Bilious) foam. Most dying creatures (including us) will suffer multiple system failure and a loss of appetite and loss of desire for water near the end.

While it is remotely possible, rabies is unlikely simply due to the "bite/exposure" being from a cat instead of a dog and from the lack of aggressive behavior.

You are doing all you can. Getting tested is wise if you can get this done for peace of mind.

I do see one significant concern that has not been discussed and that is your comment on your "newfound Valium addiction." Ramping up dosage of Valium (other Benzodiazepines also, but especially short acting ones like Valium) can cause addiction in some people in less than ten days. Benzodiazepine addiction tied with panic/anxiety is a very dangerous path. If you have been ramping up on Valium and recently cut back, there may be the cause of your severe headaches.

If Valium has become a problem I suggest finding a medical practitioner and formulate a weaning program. It is unwise to try to attempt to ramp down Valium use quickly, and to go "cold turkey" can cause death. There are other medications that one can use to reduce the anxiety that you are experiencing that will not add to the Valium addiction. I suggest strongly that if you are ramping up Valium doses, that you stabilize, stop increasing dosages, and find assistance on this issue.

Even a slight possibility of having rabies is freaky and would cause anxiety/panic in all of us. Statistics as I see them indicate that it is far more unlikely that you have rabies than it is that you do, but Valium addiction will definitely have a bite that you do not want to experience.

Please keep us informed when you get the test results. You do pretty good research, when this is all behind you perhaps you might think of a career in Public Health?

Edited February 4, 2011 by jsflynn603

[tim armstrong]

Jeebus, hard as it sounds, you need to get a grip on your stress levels.

Because you are so stressed at the moment, you're starting to catastrophize the situation, and look for the worst.

You have been given good advice, that rabies is very UNLIKELY, not likely.

Hang on to that,and investigate other causes for the symptoms being presented.

Practise saying STOP! when you are getting too worried.

Breathe, walk,and be calm with the g/f. Regards.

[jeebusjones]

Thanks for all the reassuring comments, it is hugely appreciated. As I mentioned before, I do have a history of anxiety and hypochondria, so I'm hoping that's all this is. However, I've now been experiencing these incredibly intense headaches for 8 days. They subsided a bit yesterday but have returned with a vengeance today. Like most people I've had occasional, minor headaches in the past, but nothing on this scale.

The itching/tingling sensation in my finger comes and goes, which makes me think (hope) it is a manufactured symptom.

Initially I did attribute the headaches to valium withdrawal, as they did start just when I was attempting to ween myself off of them. But even after I resumed taking them at the same dosage (I haven't increased at all), the headaches remained. I've stayed at 5mg per day and never more. Is it possible the headaches are due to my body craving higher doses?

Regarding the statistics about rabid dogs in Bangkok, I find that both reassuring and troubling. It's reassuring because according to a 1998 study I found, 54% of strays in Bangkok were found to be rabid. (abstract here: http://www.ncbi.nlm.nih.gov/pubmed/9593486) But I understand a massive vaccination campaign has been undertaken since then, so the statistic you've cited is probably accurate today.

However, it is troubling because I was not living in Bangkok. I was living in Kamphaeng Phet, and the park where we found the cat had a couple of packs of roaming dogs -- one of which I never saw again. The cat also had a wound on his back, but since he survived another 60+ days I guess rabies could potentially be ruled out. After all, quarantine time in most countries is 30 days.

The vet we took him to seemed to think he was suffering from feline leukemia, although no tests were performed and few questions asked. In fairness, the cat's symptoms did exactly match those of feline leukemia, except for the foam pooled around his mouth when we discovered his dead body. However, the foam did have a definite yellowish hue, so perhaps was the result of vomiting with an empty stomach. There also appeared to be tiny amount of blood in the foam.

We ruled out poisoning simply because he had been locked in the house for a full 2 days before his death. If he had ingested poison, could he have lived 2-5 days before dying? I really don't know.

Anyway, I agree that I need to get a handle of my stress/anxiety. The last month has been one of sheer terror from start to finish. And every doctor I've talked to (and there have been a few) has said the same thing: the cat might not have even had rabies, and even if he did our risk of contracting it was extremely low, even with the burn wound (it was approx. 5-7 days old at the time).

If these headaches would go away I might be able to put this behind me once and for all, but until then I'll be trapped in this vicious cycle of anxiety and fear.

Thanks again for all the advice and replies. It is greatly appreciated.

[Sophon]

Regarding the statistics about rabid dogs in Bangkok, I find that both reassuring and troubling. It's reassuring because according to a 1998 study I found, 54% of strays in Bangkok were found to be rabid. (abstract here: http://www.ncbi.nlm.nih.gov/pubmed/9593486) But I understand a massive vaccination campaign has been undertaken since then, so the statistic you've cited is probably accurate today.

I think you are reading the article incorrectly. It doesn't say that 54% of stray dogs in Bangkok had rabies, what it actually says is that 54% of the dogs examined tested positive for rabies. The article is not very clear on exactly which dogs were being tested, but as I understand it the dogs examined were dogs already suspected of having rabies.

Just think about it, rabies is a very deadly disease so if 50% of the stray dogs in Bangkok had rabies there would be dozens of dead soi dogs littering every soi in the city.

Sophon

[jeebusjones]

^Point taken.

[jsflynn603]

Regarding the statistics about rabid dogs in Bangkok, I find that both reassuring and troubling. It's reassuring because according to a 1998 study I found, 54% of strays in Bangkok were found to be rabid. (abstract here: http://www.ncbi.nlm..../pubmed/9593486) But I understand a massive vaccination campaign has been undertaken since then, so the statistic you've cited is probably accurate today.

I think you are reading the article incorrectly. It doesn't say that 54% of stray dogs in Bangkok had rabies, what it actually says is that 54% of the dogs examined tested positive for rabies. The article is not very clear on exactly which dogs were being tested, but as I understand it the dogs examined were dogs already suspected of having rabies.

Just think about it, rabies is a very deadly disease so if 50% of the stray dogs in Bangkok had rabies there would be dozens of dead soi dogs littering every soi in the city.

Sophon

Sophon is correct.

The article says nothing about any rabid dogs!

Let me try to explain so readers might understand the underlying concepts:

From the article this is what I believe is being discussed:

"The proportion of fluorescent antibody positive dogs, among those examined for rabies averaged 54% indicating that rabies is still a major public health threat."

A casual reader might interpret this a 54% of dogs have rabies, but this is not the case.

Your dog has puppies. You take a blood sample from the newly born puppy. The puppy will be antibody negative and the puppy is at risk, should it be bitten by a rabid animal, it will contract rabies.

Now you bring said puppy to the vet for rabies vaccination. We wait a few weeks and take a sample of said puppy's blood--the blood is now antibody positive and if bitten by a rabid animal, it is unlikely that the rabies virus will successfully replicate as the antibodies will cause destruction of the virus before it can replicate out of control. In almost all cases, even if said puppy (now antibody +) is bitten by a rabid animal the puppy will NOT get rabies.

It is good that 54% are antibody +, yet the article connotes it as bad. Why? The reason is that if the antibody + rate was, let's say, zero, it would be very bad. But let's assume that out of 100 stray dogs picked up and tested that the stated results show that 54 of them were antibody +. These dogs had a rabies vaccine, and are protected. Generally speaking they cannot get, or carry, spread rabies. But of every 100 dogs tested 46 did not have the antibody. They also did NOT have rabies.

Let's consider these 46 dogs who are antibody negative. If bitten by a rabid animal they will contract rabies. They are likely to eventually become aggressive and let's say that they bite two other dogs. If the antibody rate is 50% then statistically speaing one dog bitten becomes rabid, but the other dog, statistically will not become rabid. So at 50% antibody + rate, the rabid dog is likely to "spread" rabies to other animals. Here we can assume that the "pool" of rabid animals is likely to grow in time.

Let's say that Thai officials decide to fix this bad "only 54% are antibody + status" and divert some of the 300 million baht that they spend on human rabies intervention each year, so they capture a lot of strays, they give them a rabies vaccination and they return the dogs to the street. (Btw, this is the ONLY option other than neutering as Buddhism forbids euthanizing (killing) any dogs).

Now said Thai officials want to test the stray population to see if the situation is improved. They wait a month after this campaign and 1000 stray dogs are captured, and tested for (NOT for rabies) antibody status. Let's assume that now 700/1000 are antibody + where only 540/1000 were antibody + before the campaign. The campaign was a success. But you might say why? After all 30 out of 100 strays are still antibody negative and at risk--well let's consider this:

Let's take the case where a rabid animal bites a dog who is antibody negative (an at risk dog). In my hypothetical case this dog becomes rabid, exhibits aggressive behavior and bites two other dogs. Now though the chance of the poor bitten dogs are much better because before 46 out of 100 would become rabid, but now, after the campaign, only 30 out of 100 would become rabid. So the chance of the rabid dog successfully spreading rabies has dropped considerably.

Let's back up a bit and consider this: A 70% antibody + status amongst stray dogs is a "magic number." WHO (World Health Orginization) has made it so. This is what 70% antibody + status amongst a dog population means: It means that at this antibody + status, overall, rabies will not "get out of hand." It does not mean that no animal could get rabies it simply means that is the "critical mass" needed to prevent rabies from "spiraling out of control." A 70% overall antibody + status is what WHO recommends that every country always maintains. It also recommends that if possible a 100% antibody + status be achieved.

Bottom line: Antibody status, either positive or negative only tells you which dogs "could" become infected. The article (I could only find excerpts, not the entire article---if someone knows of a link to the full text please post in IM it to me) does not appear to say anything about any dogs being rabid.

Therefore we go back to the only data available, which says that around Bkk, one would expect to find in a random draw of strays about one in 3,000 dogs that actually has rabies.

The "cure" for Thailand is difficult because of culture and because of Buddhism. The only stop-gate cure is a campaign to pick up strays, immunize them (probably neuter them) and release them. Let's look at another country that has a similar problem. In this theoretical country an anti-rabies campaign is started: all stray dogs are shot on sight. But now we find that although the number of seropositive negative (at risk dogs) drops remarkably we also find that within a few years we're back to the same state (unless they continue to shoot strays on sight). Why? Because now the few remaining dogs (they will never get them all) will breed without restraint (with so many dogs gone there will be more food available) and in a few years you are back to a "steady-state" position. You also might find other negatives since with the dogs gone, the rat population increases. The answer is difficult, essentially impossible because strays will always be tolerated. (Unlike other countries that have no issue with picking up and euthanizing stray animals). Free vaccination, dog licensing with vaccination required, education, and "catch, vaccinate and release (with possible neutering) are the only options here.

Edited February 5, 2011 by jsflynn603

[jeebusjones]

Thanks for all that info, but I'm still freaking out here. For one thing, as I mentioned I was living in Kamphaeng Phet, where I doubt much effort has been made at vaccination.

Beyond that, it seems odd that my severe headaches could have been caused by taking just 5mg of Valium per day. On top of that, today my pupils have been noticeably dilated while indoors, though they constrict when in sunlight. I also continue to feel the itching on my finger.

Am I going crazy? Can you experience withdrawal symptoms from just 5mg of Valium per day? And are dilated pupils a symptom of that withdrawal?

[Sheryl]

Am I going crazy?

Not yet, but you will if you don't get a grip.

Can you experience withdrawal symptoms from just 5mg of Valium per day? And are dilated pupils a symptom of that withdrawal?

yes, and yes.

Lack of sleep and stress can also cause the type of HA you describe, and anxiety can also cause dilation of the pupils.

It is highly unlikely you have rabies and you can easily verify whether or not the immunizations were effective. You seem not to want to do so and to feel compelled to dwell on worst case scenarios. You need to discuss your hypochondria and anxiety (the 2 are related) with a qualified therapist.

[jeebusjones]

Thanks as always for your input Sheryl, and I sincerely hope you're right. If I do get through this I agree something needs to be done about this anxiety - it's controlling my life.

[jeebusjones]

Well the headaches have subsided, but over the last two days I've developed strange back and neck pains, of the sort I've never had before. Hopefully it's due to stress, but obviously anything involving the CNS is worrisome.

Yesterday I met with another doctor at Tan Tong Seng Hospital, and she claimed to be Singapore's foremost rabies expert. She agreed that there was a certain risk of my having contracted rabies, but her personal opinion was that I hadn't. She suggested that all of the symptoms I've been experiencing are likely due to other causes, particularly since they've been going on for so long now. Had they been due to rabies, she said, I would either be dead or in the ICU by now.

She also suggested that the itching/tingling in my finger could be due to nerve damage suffered from the burn. Strangely enough, the sensation has largely subsided since meeting with her yesterday. If I could just get past these odd back/neck pains, I think I would finally be able to relax.

She did not suggest I take any sort of test for rabies and/or rabies immunity, and I didn't push for it.

At the very least, I feel more optimistic today than I have for at least the last week. Thanks again everyone for the reassurances, and for bearing with me through my extreme anxiety and paranoia.

Oh, and she also suggested I consult a psychiatrist to help work through this extremely stressful experience.

Edited February 8, 2011 by jeebusjones