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Fatal Human Rabies Infection With Suspected Host-Mediated Failure of Post-Exposure Prophylaxis Following a Recognized

Stacy M Holzbauer^1,2, Caroline A Schrodt^3,4, Rajesh M Prabhu⁵

¹Minnesota Department of Health, St. Paul, Minnesota, USA.

Clinical Infectious Diseases : an Official Publication of the Infectious Diseases Society of America

|March 29, 2023

Summary

A rare case of rabies post-exposure prophylaxis (PEP) failure occurred in the US despite modern vaccine use. Unrecognized impaired immunity in the patient likely caused this breakthrough rabies infection.

Keywords:

bat post-exposure prophylaxis rabies vaccine failure whole-genome sequencing

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Area of Science:

Virology
Immunology
Public Health

Background:

Modern rabies vaccines are highly effective, with no documented failures in the US.
A case of rabies death occurred 6 months post-bite despite timely post-exposure prophylaxis (PEP).

Observation:

The patient, an 84-year-old male, died from rabies despite receiving PEP after a bat bite.
Medical records, WGS, and PEP biologic assessments were conducted.
Nonneutralizing rabies virus antibodies and monoclonal gammopathy were detected in the patient.

Findings:

Whole-genome sequencing confirmed identical rabies virus strains in the patient and bat.
No issues were found with PEP potency, quality, administration, or storage.
The patient had unrecognized monoclonal gammopathy and metastatic cancer, indicating impaired immunity.

Implications:

This is the first reported rabies PEP failure in the Western Hemisphere with a cell culture-based vaccine.
Host-mediated immune deficiency is the likely cause of this breakthrough rabies infection.
Consider rabies antibody titers post-PEP in immunocompromised individuals.