Rabies differential diagnosis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Mahshid Mir, M.D. [2]

Overview

The differential diagnosis for rabies deals with eliminating diseases with similar symptoms from the diagnosis. There are many viruses that can appear similar to rabies such as encephalitis and the herpes simplex virus. It is very important to rule out certain diseases such as echovirus and poliovirus. Rabies is a serious disease that needs to be treated quickly if someone is suspected to be infected with the virus.

Differentiating Rabies From Other Diseases

Rabies should be differentiated from other causes of headache and decrease consciousness:

Diseases History and Physical Diagnostic tests Other Findings
Prodromal symptoms Fever Headache LOC Neuro Onset Laboratory Findings Imaging preferance
Rabies infection[1] + + + + Insidious Antibody detection in serology

Skin biopsy of injured skin

MRI Hydrophobia, aerophobia, dysphagia, and localized pain, weakness or paresthesias
Meningitis[2][3] + + + - Sudden CSF analysis:

Leukocytes

Protein

Glucose

CT scan: First choice

MRI: Best choice

Fever, neck, rigidity
Encephalitis[4] + + + + Sudden PCR

CSF analysis and culture reveal the responsible micro-organism

MRI Accompany a meningoencephalitis, seizures, hemiparesis, cranial nerve palsies, photophobia, nausea
Autoimmune encephalitis[5] - +/- + +/- Insidious Autoantibodies present in both serum and CSF MRI

EEG

Memory deficit, dyskinesias, seizures, autonomic instability
CNS abscess[6] + + + + Insidious CSF analysis:

Leukocytes

Glucose

Protein

MRI is more sensitive and specific High grade fever, fatigue,nausea, vomiting
Poliomyelitis[7] + + + + Sudden PCR of CSF MRI Asymmetric paralysis following a flu-like syndrome
Neurosyphilis[8] - - + + Insidious CSF VDRL-specifc

CSF FTA-Ab -sensitive

MRI & Lumbar puncture History of unprotected sex or multiple sexual partners, and genital ulcer (chancre)

Blindness, confusion, depression, abnormal gait

Tick paralysis (Dermacentor tick)[9] - - +/- +/- Insidious - - History of outdoor activity in Northeastern United States

Tick often still latched to the patient at presentation (often in head and neck area)

Botulism[10] - - - - Sudden Toxin test, blood, wound, or stool culture - Diplopia, Hyporeflexia, Hypotonia, possible respiratory paralysis, Floppy baby syndrome
Tetrodotoxin poisoning[11] - - +/- +/- Sudden - - History of consumption of puffer fish species
Metabolic disturbances (electrolyte imbalance, hypoglycemia)[12] - +/- - + Sudden Hypoglycemia, hypo and hypernatremia MRI Confusion, seizure, palpitations, sweating, dizziness, hypoglycemia
Electrolyte disturbance[13] - - - +/- Insidious Hypocalcemia, hypomagnesemia, hypo- or hyperkalemia Possible arrhythmia
Drug toxicity/Neuroleptic malignant syndrome[14] - + - + Sudden Elevated serum creatine kianse

Hypocalcemia, hypomagnesemia, hypo- and hypernatremia, hyperkalemia, and metabolic acidosis

Generalized slow wave EEG Causative medications (eg, neuroleptics, antiemetics, concomitant lithium), dopaminergic withdrawal

Mental status change, rigidity, or dysautonomia

Organophosphate toxicity[15] - - - + Sudden Clinical suspicion confirmed with RBC AchE activity - History of exposure to insecticide or living in farming environment with : Diarrhea, Miosis, Bradycardia, Lacrimation, Emesis, Salivation, Sweating
Ischemic stroke[16] - - +/- + Sudden - MRI for ischemia Sudden unilateral motor and sensory deficit in a patient with a history of atherosclerotic risk factors (diabetes, hypertension, smoking) or atrial fibrillation
Hemorrhagic stroke[17] - - + + Sudden - CT scan without contrast Neck stiffness
Subdural hemorrhage[18] - - + + Sudden CSF analysis:

Xanthochromia

CT scan without contrast Confusion, dizziness, nausea, vomiting
Hypertensive encephalopathy[19] - - + + Sudden - - Delirium, cortical blindness, cerebral edema, seizure
Wernicke’s encephalopathy[20] - - - + Sudden - - Ophthalmoplegia, confusion
Amyotrophic lateral sclerosis[21] - - +/- +/- Insidious Normal LP (to rule out DDx) MRI Patient initially presents with upper motor neuron deficit (spasticity) followed by lower motor neuron deficit (flaccidity)
Diffuse gliomatosis[22] - - + - Insidious Cancer specific molecular characteristics

Normal CSF

MRI (expansile, T2 hyperintense lesion) Seizures, memory loss, motor weakness, visual symptoms, language deficit, and cognitive and personality changes
Central nervous system lymphoma[23] + - + +/- Insidious CSF cytology, flow cytometry, and stereotactic brain biopsy MRI (parenchymal or leptomeningeal enhancement) Associated with immunodeficiency

Focal neurological deficits, neuropsychiatric symptoms, signs of raised intracranial pressure, seizures, and ocular symptoms

The most important differential diagnosis when it comes to the rabies presentations include meningitis and encephalitis. It is important to differentiate different rabies from each one of the causes of meningitis/encephalitis, which may differ based on the season of occurrence and the geographical region.

The most important viruses to rule out are:[24][25]

In addition, consideration should be given to the local epidemiology of encephalitis caused by arboviruses belonging to several taxonomic groups, including:

New causes of viral encephalitis are also possible, as was evidenced by the recent outbreak in Malaysia of some 300 cases of encephalitis (mortality rate, 40%) caused by Nipah virus, a newly recognized paramyxovirus. Similarly, well-known viruses may be introduced into new locations, as is illustrated by the recent outbreak of encephalitis due to West Nile virus in the eastern United States. Epidemiological factors (e.g., season, geographic location, and the patient’s age, travel history, and possible exposure to animal bites, rodents, and ticks) may help direct the diagnostic workup.

References

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