An unusual presentation of rabies despite post-exposure prophylaxis

Rabies is a fatal zoonotic disease spread through dog bites. Although post-exposure prophylaxis is known to offer complete protection, there are isolated case reports of disease occurrence despite vaccination. We report a case of a 20 year old gentleman. He sustained a category 3 exposure on the upper limb following which he received 4 doses of purified chick embryo cell culture vaccine. However, the rabies immunoglobulin was not given. He presented with flaccid areflexic quadriparesis and absent brainstem reflexes 18 days following the exposure. He lacked the characteristic hydrophobia and aerophobia. Diagnosis of rabies was confirmed by the CSF antibody demonstration on RFFIT (rapid fluorescent focus inhibition test). The patient succumbed to the illness on day 25 following the dog bite. Paralytic variant of rabies is rare but described often in the setting of vaccine failure. Routine administration of rabies immunoglobulin in addition to vaccination is the key in prevention of vaccine failure.