Rabies post-exposure prophylaxis after previous immediate hypersensitivity: A case report

Rabies is almost invariably fatal after symptom onset but is preventable with timely post-exposure prophylaxis. A 23-year-old woman presented after a category III stray-cat bite. In 2022, tongue swelling and generalized urticaria had occurred immediately after her first rabies vaccine dose, and the series was discontinued. Because the new exposure was high risk and she was not fully immunized, prophylaxis was administered in a resuscitation area with intramuscular epinephrine and advanced airway equipment immediately available. Equine rabies immunoglobulin and vaccine were given after antihistamine and corticosteroid premedication. Only transient localized erythema occurred. After the first two doses were tolerated during 16- and 8-h observation periods, the third and fourth doses were administered after oral cetirizine with 4-h monitoring in a standard monitored area. After individualized assessment, prophylaxis may be completed despite previous immediate hypersensitivity when full resuscitation preparedness and progressive de-escalation of monitoring are used. Premedication does not prevent anaphylaxis and must not replace prompt epinephrine treatment.