Case Report: Paralytic rabies masquerading as traumatic spinal cord injury: a diagnostic pitfall in trauma surgery

Rabies is a uniformly fatal zoonotic encephalitis. Its paralytic form, which accounts for approximately 20% of cases, frequently resembles acute spinal cord injury (SCI). When there is a coincident history of trauma, diagnostic anchoring may wrongly attribute neurological decline to the injury, thereby delaying the correct diagnosis. We describe the case of a 26-year-old man who developed progressive, ascending paralysis of the lower limbs 10 days after a 3-m fall. At a secondary hospital, he was clinically diagnosed with traumatic SCI without spinal MRI. On transfer, reassessment revealed a fox bite 4 months earlier and features of the hydrophobia variant (a sensation of water "entering the brain" during swallowing). Cerebrospinal fluid metagenomic next-generation sequencing (mNGS) detected Rabies lyssavirus within 48 h, showing 100% sequence identity to Chinese isolates spanning the N and L genes. This finding was subsequently confirmed by the Sichuan Provincial Center for Disease Control and Prevention (CDC) using standard reference testing on peripheral blood. The patient subsequently died of autonomic and respiratory failure. This case highlights how recent trauma can obscure a fatal infectious cause. A clinical diagnosis of SCI made without neuroimaging should be regarded as provisional, and mNGS can provide an unbiased, rapid means of resolving diagnostically challenging neurological presentations.