RABIES

Dr.Stefany Adi.W,SpPD
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Definisi

Rabies adalah penyakit infeksi akut

susunan saraf pusat pada manusia
dan mamalia yang berakibat fatal.
Disebabkan oleh virus rabies,genus
Lyssa-virus, famili Rhabdoviridae dan
menginfeksi manusia melalui secret
yang terinfeksi pada gigitan
binatang.
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Etiology

Virus Rabies merupakan prototipe

dari genus Lyssa virus dari famili
Rabdoviridae.
Dari genus Lyssa virus ada 11 jenis
virus yg secara antigenik mirip rabies
dan yg menginfeksi manusia adalah
virus rabies, Mokola, Duvenhage,
dan European bat lyssa-virus.
Termasuk golongan virus RNA.
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Morphology

Order- Mononegavirales
Nonsegmented
Negative stranded RNA
genome
Bullet shapedRhabdovirus 180nm
x75nm
400 trimeric spikes on
surface of virus
2 major structural
components
Helical RNP core
Surrounding envelope

Physiology

Genome encodes 5 proteins:

Nucleoprotein- encases RNA

Phosphoprotein- associated with ribonuceoprotein core
Matrix protein- central protein of rhabdovirus assembly
Glycoprotein- forms 400 trimeric spikes
Polymerase- transcribes genomic strand of rabies RNA

Distribusi dan Insiden

Jumlah kematian didunia 50.000

org/thn,terbanyak asia dan afrika.
1999-2003:Indonesia, tersangka rata2
12.400 kasus, terbukti rabies 76
kasus/thn.
2000; kasus rabies plg banyak dari
prop.NTT (59 kasus);2001 (11 kasus).
Di Indonesia, binatang penggigit yang
plg banyak : anjing (90%), kucing
(6%),kera dll(4%). Di Eropa terbanyak
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racoon,kelelawar.

Transmisi

Infeksi terjadi melalui kontak dgn

binatang spt anjing, kera, serigala,
kelelawar dan ditularkan ke manusia
melalui gigitan binatang atau kontak
virus (saliva) dengan luka atau
membran mukosa.

Transmission

In wild animals: Rabies can be

transmitted transplacentally
Transplants in human- possible
Human-to-human: Never has been
confirmed
Rabies virus never isolated from
blood
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Transmission

Almost all
transmission is by
bite
50 times greater risk
than a scratch
One human case may
have been acquired
in a laboratory
(transmitted by
aerosol)
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Patogenesis

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Virus lifestyle

Virus replicated in muscle cells near site of

bite for most of incubation time.
Incubation time 30-90 days. Latency up to 7
years

Then ascends along motor and sensory

axons at rate of 12-100mm/day and has
predilection for brainstem and medulla
Enters salivary glands after replication in
CNS.
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Gejala Klinis

Masa Inkubasi : 1-3 bulan, 95%kurang

dari 1 thn, Paling pendek 10-20 hari
(thailand).
Lama masa inkubasi dipengaruhi oleh
besarnya luka gigitan, lokasi luka gigitan
(jauh dekatnya ke ssp), derajat
patogenesis virus, persarafan daerah luka
gigitan. Luka di kepala inkubassi 25-48
hari, pada ekstremitas 46-78 hari.
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MANIFESTASI KLINIS RABIES

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Clinical Features

Prodrome: HA, fever, rhinorrhea,

sore throat, myalgias, GI upset.
*Back pain and muscle spasms.
Agitation and anxiety may result in
diagnosis of psychosis or intoxication
Paresthesias, pain or severe itching
at site may be the first neurological
symptom.
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Encephalitic Form

Hydrophobia: Patient cant swallow

because violent jerky contraction of
diaphragm and accessory muscles of
inspiration when pt attempts to
swallow liquids
- Patients will be terrified during
this reaction and may even
experience this at the sight of water
or if water touches their face.
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Encephalitic Form

Aerophobia: an extreme fear of air

in motion can be elicited from some
patients. This can also cause violent
muscle spasms in the neck and
pharynx.
Hallucinations, seizures, ataxia, focal
weakness and arrhythmias can occur.

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Paralytic Rabies

Other form is dumb or paralytic

rabies. Similar to Guillain-Barre.
Prominent limb weakness. Consciousness
initially spared

Two forms can overlap or progress

from one to the other
Coma after one week of neuro
symptoms with death a few days after.
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Animal Behavior

Classic Picture of
rabid, mangy dog
foaming at the
mouthnot often
seen, signs frequently
more subtle.
Animals can display
aggressive behavior,
ataxia, irritability,
anorexia, lethargy or
excessive salivation.
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Animal Behavior

Cats are more likely to be aggressive

than dogs
Animals exhibit change in instinctive
behavior: nocturnal animal walking
around in daylight (i.e. raccoons)
Unprovoked bites
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KOMPLIKASI PADA RABIES DAN PENANGANANNYA

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Pemeriksaan Penunjang

DL : awal penyakit;Hb normal/sedikit turun, leukosit

normal atau leukositosis,monositosis.
UL; leukosituria,albuminuria
CSS : gambaran ensepalitis; peningkatan leukosit.
Isolasi virus ada mgg I dari saliva, hapusan
tenggorok,trakea, kornea, biopsi kulit/otak ,CSS,urin
FAT (Fluorescent antibody test):deteksi antigen virus
rabies di jaringan otak CSS,urin.
RFFIT (Rapid Fluorescent Focus Inhibition Test):
deteksi antibody spesifik 48 jam.
71-90%: histologis jaringan otak ditemukan negri
bodies.
RT-PCR :deteksi RNA virus rabies (Reverse
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Transcriptase polymerase Chain Reaction)

Negri bodies : asidofilik,butir2 basofilik didalamnya.

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Diagnosis Banding

Rabies histerik
Tetanus
Guilain barre syndrome
Transverse myelitis
Japanese encephalitis

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Penanganan

Tidak ada terapi untuk pasien yg

sudah menunjukkan gejala rabies :
terapi suportif.
Pencegahan : perawatan luka,
VAR(vaksin anti rabies),
imunoglobulin/SAR (serum anti
rabies)

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Management

Once symptoms occur: fatal in 3-10

days
ICU support: can prolong 4 months.

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Management

No effective treatment exists.

Postexposure Prophylaxis/PEP: 3 steps
1. Wound care: immediate thorough
washing with soap and water and a virucidal
agent such as povidine-iodine or 1-2%
benzalkonium chloride.

Shown to be protective if performed within 3 hours of

exposure
If puncture, swab deeply in wound and around edges

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PEP

2. Passive Immunization: Human

rabies immunoglobulin (HRIG) 20
IU/kgBW , but not longer than 7 days
after vaccine given. Infiltrate entire dose
around wound, any remaining IG inject
IM at a site distant from the vaccine.
3. Human diploid cell vaccine
(HDCV): 1 ml (deltoid) on days
0,3,7,14,28.(WHO); 0,7,21(depkes)
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PEP

Vaccine: do not give in gluteal. If

injected into fat, no antibodies
formed.
HRIG and HDCV: give in different
anatomical sites and never in the
same syringe.
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PEP

Local Reactions: itching, erythema,

pain, swelling
Systemic: HA, myalgia, nausea.
Anaphylaxis: .1% of cases
Guillain-Barre: 3 cases
Angiodema: 6% of pts who receive
boosters.
Can give PEP during pregnancy
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Who should get PEP?

Type of exposure

Location of incident (head/neck)

Species of biting animal (common

carrier of rabies?)

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WHAT IS A
SIGNIFICANT
EXPOSURE?
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Significant Exposure

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Significant Exposure

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Significant Exposure

Bites are significant

Nonbite exposures that involve
contamination of either mucous
membrane or open wound (bled
within 24 hours) with saliva
Not significant: petting a rabid
animal, contact with its blood, urine,
feces.
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Animals in captivity

Wild animals that are

caught should by
euthanized immediately
and head sent under
refrigeration to an
appropriate lab for testing.
Domestic animals that are
apparently healthy should
be observed for 10 days.
If animal doesnt become
ill, victim does not require
treatment.
If animal gets sick,
euthanize and test
immediately.
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Vaksinasi Pre-exposure

Untuk individu yg beresiko tinggi

kontak dengan virus rabies (drh,
pekerja kebun binatang, petugas
karantina hewan,petugas lab.,
dr.,perawat yg menangani pasien
rabies.
VAR(HDCV) 1 ml im (area deltoid)
hari 0,7,28,booster setelah 1 thn dan
tiap 5 thn.
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Control and Prevention

Pre-exposure prophylaxis vaccination

Post-exposure prophylaxis
If you are exposed to a possible
rabid animal:
Wash wound with soap and water
Seek medical attention immediately

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Control and Prevention

Be a responsible pet owner

Keep vaccinations up to date
Keep pets under direct supervision

Enjoy wild animals from far away

Dont adopt wild animals
Love your own, leave others alone
policy
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Prognosis

Prognosis rabies sebenarnya tidak ada

harapan/tetap jelek dengan akibat kematian.
Sejak thn 1875 dilaporkan 10 pasien yg
sembuh dari rabies atau bila dpt bertahan
hidup akan terdapat neurological sequele yg
berat.
Thn 1972 smp sekarang blm ada pasien rabies
yg dilaporkan hidup.
Prognosis rabies selalu fatal karena sekali
gejala rabies telah tampak kematian selalu
terjadi 2-3 hari sesudahnya akibat gagal
napas, henti jantung atau paralisis
generalisata.
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