Y.H. Hsu, L.C. Cho, L.S. Wang, et al
ACUTE RESPIRATORY DISTRESS SYNDROME ASSOCIATED WITH RABIES: A CASE REPORT 1
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Yung-Hsiang Hsu, Li-Chen Cho, Lih-Shinn Wang, Li-Kuang Chen, Jen-Jyh Lee, and Hui-Hua Yang5 2 3 4 5 Departments of Pathology, Infectious Disease, Emergency, Chest, and Virology, 1 Buddhist Tzu-Chi General Hospital, and Department of Nursing, Buddhist Tzh-Chi College of Technology, Hualien, Taiwan.
Acute respiratory distress syndrome (ARDS) is the first potentially lethal complication in rabies virus infection, although its occurrence is rare. We report on a fatal case of rabies virus infection in a 45-year-old woman from Hu-Nan Province, China. The neurologic signs of limb numbness and water phobia occurred from 61 days after the dog bite; the clinical course was progressive, with the most severe clinical manifestations being fever, encephalitis, and ARDS. The woman expired 12 days after admission to the hospital. An autopsy proved rabies encephalitis, mainly involving the medulla oblongata, the thalamus, part of the pons, the cerebellum, and the hippocampus. The lung pathologic examination revealed the organizing phase of ARDS with diffuse alveolar damage, hyaline membrane formation, type II alveolar cell hyperplasia accompanied by proliferation of fibroblasts and infiltration of mononuclear cells into the interstitial space. Immunohistochemistry stain and reverse transcription-polymerase chain reaction for rabies virus failed to demonstrate the organism in the lung tissue. Strong expression of inducible nitric oxide synthase (iNOS) was detected in the alveolar macrophages. An immunologic mechanism with iNOS expression in the absence of direct invasion of the organism may participate in the pathogenesis of ARDS associated with rabies.
Key Words: rabies, acute respiratory distress syndrome (ARDS), inducible nitric oxide synthase (iNOS) (Kaohsiung J Med Sci 2006;22:94–8)
Taiwan has been rabies-free since 1958 [1]. Rabies is mainly transmitted to both humans and animals through bites by rabid animals. After traumatic inoculation of virus from infectious saliva, rabies virus may either persist and replicate at the inoculation sites for hours to weeks [2,3], or follow a relatively rapid centripetal course to the central nervous system [4]. Eventually, rabies encephalitis develops, followed by fatal complications such as acute respiratory distress syndrome (ARDS) and myocarditis [5]. ARDS is the first potentially lethal complication in rabies virus infection. Udwadia et al [6] reported the first rabies-
Received: August 18, 2005 Accepted: October 12, 2005 Address correspondence and reprint requests to: Dr. Yung-Hsiang Hsu, Department of Pathology, Buddhist Tzu-Chi General Hospital, 707, Section 3, Chung Yang Road, Hualien 94007, Taiwan. E-mail:
[email protected]
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associated ARDS case on day 7 of hospitalization. We report here an autopsy-proven rabies virus infection complicated by ARDS in a 45-year-old woman from Hu-Nan Province, China. The pathogenesis of ARDS associated with rabies is unknown. In this study, we will discuss the pathogenesis of this association.
CASE PRESENTATION A 45-year-old woman was bitten on her left wrist and right leg by a puppy on 29 April 2002 in Hu-Nan Province, China. At the time, she did not receive postexposure prophylactic vaccination for rabies, and the puppy was killed without observation. On 2 May 2002 she visited her sister in Yu-Li, Hualien, Taiwan. While there, she had symptoms of hydrophobia on 29 June 2002 and was brought to Yu-Li Kaohsiung J Med Sci February 2006 • Vol 22 • No 2 © 2006 Elsevier. All rights reserved.
Rabies-associated ARDS
Veterans Hospital. She was transferred to our hospital on suspicion of rabies. In the emergency department, her pulse rate was 80 beats/min, respiratory rate 18 breaths/min, blood pressure 130/70 mmHg, and body temperature 38°C (100.4°F). A chest radiograph showed normal appearance (Figure 1A). On neurologic examination, the patient was lucid, oriented, and cooperative. After admission, the patient became irritable, and haloperidol and ativan injections were given. Her fever increased to 38.5°C, and leukocytosis with a left shift was noted (white blood cell count 19,200 cells/µL, neutrophil segment 87%). Blood culture was performed on 30 June. Sudden onset of apnea developed on the night of 30 June, and endotracheal intubation was performed. Her respiration was subsequently supported by mechanical ventilation. Low blood pressure (systolic, 70–90 mm Hg) was noted at 3:00 a.m. on 1 July, and dopamine was given. Empirical antibiotic treatment with ceftriaxone (2000 mg intravenously every 8 hours) was given from 1 July to 3 July. Her fever was under control at 37°C (98.6°F) on 3 July. The first dose of rabies immunoglobulin injection and vaccine was administered intramuscularly in the afternoon of 1 July. Lumbar puncture was performed on the same day and, later, a cerebrospinal fluid study showed all parameters within normal limits. Another dose of rabies vaccine was injected on 3 July. Chest radiography was performed again on 5 July (day 7 after admission) and showed marked lung infiltration (Figure 1B). Moxifloxacin (400 mg/day) and rifampicin (300 mg every 12 hours) plus ribavirin
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(1000 mg/day) were prescribed on 5 July. Arrhythmia with an S4 sound was detected. Ativan was started on 6 July because of her irritability. Her blood pressure dropped to 60/40 mm Hg on 8 July, and norepinephrine was prescribed to maintain blood pressure. Multiple atrial and ventricular premature contractions in bigeminy and trigeminy presentation were noted on electrocardiography, and lidocaine 1 vial drip in normal saline for more than 5 minutes was given for control of these symptoms. On 9 July, the Glasgow Coma Scale decreased to E1VtM1. Neurologic examination showed negative Doll’s eyes sign, and unequal pupil size (right/left, 5 mm/4 mm). Pupillary light reflex and gag reflex were also absent. Fundoscopy showed bilateral papilledema. Her blood pressure dropped on 10 July even with the addition of dopamine and levophed. She died at 3:00 a.m., 12 days after admission. An autopsy was performed 12 hours after death. Tissues from various organs were fixed in 10% buffered formalin and embedded in paraffin. Histologic examination was performed using hematoxylin-eosin (H&E) stain from paraffin section. Immunohistochemistry stain with anti-rabies antibody (Neo Marker) and antibody to inducible nitric oxide synthase (iNOS) (Dako, Denmark) using the antigen retrieval method [7] with LSAB kit (Dako, Denmark) for brain and lung, and reverse transcription-polymerase chain reaction (RT-PCR) [8] was also performed to detect the rabies virus genome using fresh tissue from the medulla oblongata, cerebellum, and lung.
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Figure 1. (A) Normal chest posteroanterior (PA) radiograph on 29 June 2002 (day 1 of hospitalization). (B) Chest PA radiograph showing marked diffuse pulmonary infiltration on 5 July 2002 (day 7 of hospitalization). Kaohsiung J Med Sci February 2006 • Vol 22 • No 2
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Y.H. Hsu, L.C. Cho, L.S. Wang, et al
RESULTS Gross findings Multiple petechial lesions involved the whole brain stem and thalamus. Marked congestion, edema, and focal hemorrhage were seen in both lungs (right 720 g, left 700 g).
Histology, immunohistochemistry, and RT-PCR findings The findings were typical of rabies encephalitis, with perivascular lymphocytic cuffing, glial nodules formation, and neuronophagia (Figure 2A) involving mainly the medulla oblongata, a part of the pons, thalamus,
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cerebellum, and hippocampus, which were confirmed by immunohistochemistry stain using anti-rabies antibody (Figure 2B) and RT-PCR. Diagnostic eosinophilic Negri body (Figure 3) was also found in the above lesions. Both lungs showed diffuse alveolar damage accompanied by type II alveolar cell hyperplasia, fibroblast proliferation, and mononuclear cell infiltration into the interstitial space consistent with the organizing phase of ARDS (Figure 4A). In addition, no evidence of rabies virus genome and rabies protein in lung tissue was found on RT-PCR and immunohistochemistry stain. Immunohistochemistry stain also showed diffuse iNOS expression in the alveolar macrophages (Figure 4B).
DISCUSSION ARDS was the first potentially lethal complication in a previous report, although its occurrence is rare [5]. In our patient, ARDS developed on day 7 of hospitalization, as previously reported [6]. The lung pathologic specimen revealed diffuse alveolar damage with hyaline membrane formation accompanied by type II alveolar cell hyperplasia, fibroblast proliferation, and mononuclear cell infiltration in the interstitial space consistent with the organizing phase of ARDS lasting about 1 week [9]. There was no known precipitating condition for ARDS in our patient, such as sepsis or aspiration. Although rabies virus protein was
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Figure 2. (A) Perivascular lymphocytic cuffing with neuronophagia and neural glial nodules formation in medulla oblongata (H&E, original magnification × 40). (B) Immunohistochemistry shows rabies virus antigen in the cytoplasm of infected neuron (arrow) of the medulla oblongata (AEC, original magnification × 100).
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Figure 3. Eosinophilic Negri bodies (arrow) formation in the Purkinje cells of the cerebellum (H&E, original magnification × 200).
Kaohsiung J Med Sci February 2006 • Vol 22 • No 2
Rabies-associated ARDS
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Figure 4. (A) Diffuse alveolar damage with type II alveolar cell hyperplasia accompanied by proliferation of fibroblasts and infiltration by a few mononuclear cells into the interstitial space (H&E, original magnification × 200). (B) Immunohistochemistry stain shows strong inducible nitric oxide synthase expression in the alveolar macrophages (AEC, original magnification × 100).
not demonstrated using immunohistochemistry stain, and RT-PCR failed to show rabies virus genome in the lung tissue, we suggest that rabies-associated ARDS could be due to a cytokine storm of an immune response to rabies infection. Human alveolar macrophages and monocytes are a source for nitric oxide (NO) production [10]. Our research demonstrated strong iNOS protein expression in the alveolar macrophage. We postulate that the massive production of NO through iNOS activation is the main cause of rabiesassociated ARDS. Oxidants may interact with NO to form toxic compounds (e.g., NO combines with superoxide anion to form peroxynitrite). Furthermore, such reactions may activate nuclear factor-κB expression. This could then be followed by expression of inflammatory cytokines such as interleukin-1 and tumor necrosis factor-α [10]. This mechanism is the same as enterovirus 71-associated pulmonary edema [11,12]. In conclusion, in our case, immunologic response in the lung to rabies virus infection with iNOS expression might explain the pathogenesis of ARDS. To our knowledge , this is the first autopsy-proven ARDS case report associated with rabies.
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immunofluorescence light and electron microscopic studies. Lab Invest 1979;41:36–44. Charlton KM, Casey GA, Webster WA, et al. Experimental rabies in skunks and foxes. Pathogenesis of the spongiform lesions. Lab Invest 1987;57:634–45. Baer GM. Pathogenesis to the central nervous system. In: Baer GM, ed. The Natural History of Rabies. New York: Academic, 1975:191. Corey L. Rabies and other rhabdoviruses. In: Braunwald E, Isselbacher K, Petersdorf R, et al, eds. Harrison’s Principles of th Internal Medicine, 11 edition. New York: McGraw-Hill, 1987: 712–7. Udwadia ZF, Udwadia FE, Katrak SM, et al. Human rabies: clinical features, diagnosis, complications, and management. Crit Care Med 1989;17:834–6. Shi SR, Key ME, Malra KL. Antigen retrieval in formalinfixed, paraffin-embedded tissues: an enhancement method for immunohistochemical staining based on microwave oven heating of tissue sections. J Histochem Cytochem 1991;39:741–8. Kamolvarin N, Tirawatnpong T, Rattanasiwamoke R, et al. Diagnosis of rabies by polymerase chain reaction with nested primers. J Infect Dis 1993;167:207–10. Tomashefski JF. Pulmonary pathology of the adult respiratory distress syndrome. Clin Chest Med 1990;11:593–619. Thomassen MJ, Kavura MS. Human alveolar macrophages and monocytes as a source and target for nitric oxide. Int Immunopharmacol 2001;1:1479–90. Kao SJ, Yang FL, Hsu YH, et al. Mechanism of fulminant pulmonary edema caused by enterovirus 71. Clin Infect Dis 2004;38:1784–8. Wang SM, Lei HY, Huang KJ, et al. Pathogenesis of enterovirus 71 brainstem encephalitis in pediatric patients: role of cytokines and cellular immune activation in patients with pulmonary edema. J Infect Dis 2003;188:564–70.
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