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To the Editor-in-Chief:

The recent review on clinical management of monkey bites in travelers was timely and informative, and highlighted the potential risk of rabies following exposure to non-human primates (NHP) in rabies-enzootic regions.1

Recently, we encountered a case of human rabies following an uncommon mode of exposure to NHP. A 45-year-old male, from a village in Andhra Pradesh, a southern state in India, presented to a local physician with 2 days history of painful involuntary contractions of pharyngeal muscles on exposure to air and liquids, causing choking. On recognition of these classical symptoms of aerophobia and hydrophobia, he was referred to the Infectious Disease Hospital. The patient had had a history of monkey bite on his left upper arm three weeks prior; he had apparently climbed a palm tree to consume toddy tapped in a pot, when he was suddenly attacked and bitten by a monkey—the exact species was not known. The patient did not seek medical advice and hence did not receive post-exposure prophylaxis (PEP). On examination, patient was found agitated, delirious and had hallucinations. He lapsed into coma and died within a day of hospital admission. Rabies virus neutralizing antibody titre by rapid fluorescent focus inhibition test (RFFIT) in his serum was 512, which was suggestive of rabies in a non vaccinated individual. Saliva was positive for rabies viral RNA by real-time PCR confirming rabies encephalitis. Laboratory confirmation can validate a clinical diagnosis, especially in patients with uncommon/unusual exposures or atypical clinical presentation and help in case closure and grief counseling of family members.

Issue Section:
Letter to the Editor
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