Age: 19.0
Sex: F
Vaccine: RAB, RAB
Symptoms: Insomnia, Judgement impaired, Liver function test normal, Memory impairment, Metabolic function test normal
Clinical narrative: Case number PHHY2014US140185, is an initial literature report received on 27 Oct 2014. The authors discuss about psychotic disorder after contact with a potentially rabid animal and post-exposure prophylactic anti-rabies treatment. This report refers to a 19-year-old female patient. Medical history included bitten by a stray dog, presenting with a bleeding and dirty wound on her left calf from the bite. Post dog bite, she was vaccinated with rabies vaccine (manufacturer and batch number unknown) (Day 1). A week later (Day 8), she was brought back to receive her second shot of rabies vaccine. Over two days following her second shot, she developed difficulties sleeping, reported hearing multiple voices including her father's in the background and appeared extremely preoccupied, stating "thank God I'm alive". The patient's mother also reported that, four days after patient's second vaccine shot (Day 12), the patient's sister called her stating that the patient was anxiously packing her belongings and repeating "there are demons in the house, I can't stay". According to the mother, the patient's symptoms worsened further over the following two days, so the patient went to stay with her father, who lives separately (Day 14). The mother stated that while staying with her father, the patient appeared extremely anxious and confused with simple tasks such as inserting braces for her teeth or putting on eyeglasses. On one day, the mother had gone to see her daughter at the father's house and found her making strange grunting noises and unable to recognize her. The mother informed the father of this behavior. The patient was brought overnight to Psychiatric Emergency Room (PER) (Day 15), by ambulance and police after her father called emergency services because the patient whom he was accompanying to the hospital to be evaluated for bizarre behavior had jumped out of his car onto the highway and started running barefoot and screaming in the middle of traffic. The patient told emergency services that she had a panic attack while she was in the car with her father because "he was trying to molest her". According to the parents, the patient had no other significant medical history, but has been diagnosed with a learning disability since age 8. Patient was enrolled in the 9th grade at a special education high school and also worked part time at a cleaning job. Both she and her parents were unaware of any drug allergy and both she and her parents denied any personal or family history of psychiatric illness, suicide or substance use. During her first re-evaluation, the patient denied any sexual, physical or emotional abuse and any history of violence or trauma. Patient denied any history of cigarette smoking, alcohol use, or illicit drug use. Patient also denied any symptoms of mania or mood disorder. On mental status examination, the patient presented dressed in casual clothes and with ungroomed curly hair. Hygiene was fair. Psychomotor activity was increased. She appeared confused, scared, and guarded; cooperation was superficial. Mood was anxious, affect constricted. She occasionally appeared to be internally preoccupied and reported hearing multiple voices, although she was unable to understand their words. She also reported seeing demons. She denied suicidal or homicidal ideation, intent or plan. Memory, attention and concentration were poor, as were insight and judgment. Impulse control was intact. On physical examination, she was spiking a fever of 100.6 to 100.8 F (38.1 to 38.2 C). The remaining vitals were stable. She appeared malnourished and reported no desire to eat or drink. A review of systems was normal except for a partially healed bite would on her left calf. Complete blood count, comprehensive metabolic panel, urine toxicology, electrocardiogram (EKG), urine analysis, urine pregnancy and head Computerised tomogram (CT) scan were all within normal limits. She was diagnosed with psychosis not otherwise specified, psychosis secondary to general medical condition, such as rabies or rabies vaccine and learning disorder not otherwise specified. In the PER, the patient was started on haloperidol 2 mg by mouth mornings and evenings, lorazepam 1 mg by mouth twice/day and olanzapine 5 mg by mouth evenings. Amoxicillin 875 mg/clavulanate potassium 125 mg by mouth every 12 hours was added to counter any bacterial infection at the origin of the fever. She was also encouraged to rehydrate by mouth, which she eventually agreed to do. She was admitted to inpatient Psychiatric Unit and was discharged after two weeks on olanzapine 5 mg by mouth twice/day and clonazepam 0.5 mg by mouth evenings. Two days later, she was brought back to the PER by emergency services accompanied by her mother due to bizarre behavior. The mother reported that her daughter was reporting phrases such as "I am confused", "I am scared" and "I might be dead". Repeated lab exams showed increased liver enzymes from the previous PER visit (Alanine aminotransferase (ALT) 58 to 670 U/L, Aspartate aminotransferase (AST) 114 to 255 U/L). Olanzapine was discontinued, and she was started on quetiapine 100 mg twice/day. The patient was admitted to Inpatient Psychiatric Unit for another three weeks until discharge. Repeat liver function exams at discharge were within normal limits. The patient completed the vaccination series and she was stable on quetiapine. One month after discharge, she was briefly rehospitalized, although at another institution, and since discharge circa nine months ago has been non-compliant with both medications and follow-up. She was described by her mother as no longer being symptomatic and as having resumed work.