TRANSMISSION OF RABIES VIRUS THROUGH A CONTACT LENS CONTAMINATED WITH SALIVA FROM AN INFECTED DOG (CASE REPORT)

The aim of the present work was to describe the clinical course of rabies in a 9-year-old boy with progressive rabies symptoms and fatal outcome after atypical exposure to the virus through a contact lens contaminated with saliva from an infected dog. Epidanamnesis data. The patient is a third-grade elementary school student, was admitted to the emergency department of Kutaisi Infectious Diseases Hospital, with fever, periodic dyspnea, malaise, headache, lacrimation, nasal congestion, sore throat, lack of appetite and insomnia. The boy became acutely ill three days before hospitalization, complaining of chills (fever up to 38.5°C), pain in the area of the right eyebrow, redness of the right eye, lacrimation and nasal congestion. In the following days, against the background of persisting symptoms, appetite decreased, and sleep was disturbed. Short attacks of dyspnea, unexplained anxiety and fear of suffocation arose intermittently, mainly when drinking water. On objective physical examination: the medical condition is moderate severity. Fever of 37.8°C. There is no evidence of skin discoloration or rash. The mucous membrane of the oropharynx is slightly hyperemic, tonsils are not enlarged, except for single enlarged but painless lymph nodes palpated in the submandibular and cervical regions. Redness of the right eye, lacrimation and photophobia are noted. The cardiac silhouette is not enlarged, heart sounds and cardiac rhythm are normal, HR 70/min, BP 100/75 mm Hg. Chest is clear to auscultation, no wheezing, respiratory rate 17/min, oxygen saturation index is within normal limits (SpO2 ≥ 98% on room air). The tongue is moist, covered with white plaque. The abdomen is soft and painless on palpation without organomegaly. A full blood count (FBC) test reveals mildly elevated leukocytes of 15.0 x 109/L, immature neutrophils count greater than 10%, urinalysis shows albuminuria, cylindroid and leukocyturia (12-15 WBCs/hpf). Neurological status: the patient is conscious, with no meningeal or focal symptoms. Gait is stable and smooth. Cranial nerves are intact. In the following days, the boy's condition began to gradually deteriorate. Clinical manifestations include pronounced signs: weakness, headache, insomnia, constant fear, lack of appetite, decreased mood, periodic feeling of "breathlessness", keratoconjunctivitis of the right eye, photophobia, lachrymation, salivation and hyperhidrosis. When the patient drinks water in small sips, he develops a feeling of fear and fear of choking. Brief attacks of convulsive respiratory movements occur periodically at rest. Visual and tactile hallucinations are also noted. The attacks of aerophobia are inconstant. Based on the dynamics of clinical features of the disease, the diagnosis of "rabies" was established. When delving into the exposure history, important information was obtained from the patient's classmate. It was found that 15 days before hospitalization, a stray dog had attacked the child (near the school). During the attack, the boy's lens fell out of his right eye and the dog managed to salivate it. The child rinsed the lens with running water and put it back on. On hospital day 5, the patient's condition has become more severe. Paresis of the lower extremities was pronounced. When doing the Barre test, the boy could not keep his legs in an elevated position. Flexion and extension of legs with weakened strength. He could not get out of bed. The patient developed a sudden increase in body temperature (≥39.5°C), hyperhidrosis and cold extremities. He was lethargic and had difficulty concentrating on the interviewer's questions. Symptoms of tachypnea (32 breaths per minute), blue lips and acrocyanosis were associated with increasing respiratory failure. BP - 130/90 mm Hg, HR - 100 per minute. On the background of signs of respiratory failure and hemodynamic instability, biological death was stated (about 20 days after contact with the infected dog). A postmortem study confirmed the presence of street rabies virus in a bioassay on white mice. Typically, the incubation period for rabies ranges from 30 to 90 days. However, the entry of rabies virus onto the corneal surface can be equated to intracerebral infection, which ultimately predetermined the rapid spread of infections with a very short incubation period (only 15 days). Of note, our patient was already in the agitation period at the time of admission to the hospital, and the pathological changes in the CNS were irreversible. In summary, this clinical case highlights the importance of considering all possible routes of rabies virus transmission and increasing clinician vigilance regarding timely epidanamnesis collection for early rabies diagnosis, as only timely post-exposure prophylaxis can save the patient's life.