J Neurocrit Care.  2021 Jun;14(1):52-56. 10.18700/jnc.210005.

Paralytic rabies mimicking Guillain-Barré syndrome: the dilemma still prevails

• Surve RM
• Pendharkar HS
• Bansal S

• KMID: 2517133
• DOI: http://doi.org/10.18700/jnc.210005

Abstract

Background
Paralytic rabies lacks the hallmark signs of rabies at presentation and is often misdiagnosed as Guillain-Barre Syndrome (GBS). Sensitive antemortem diagnostic criteria for rabies is lacking, and the diagnosis is confirmed posthumously by demonstrating Negri bodies on brain biopsy. Antemortem magnetic resonance imaging (MRI) brain/spine findings have recently been reported for paralytic rabies, which might be helpful in the early diagnosis of paralytic rabies.
Case Report
We report a case of paralytic rabies in a young boy who was initially misdiagnosed with GBS. In this case, brain and spine magnetic resonance imaging (MRI) findings pointed towards paralytic rabies, which was confirmed by the presence of anti-rabies antibodies in the serum and cerebrospinal fluid analysis, and posthumously by Negri bodies on brain biopsy.
Conclusion
In patients with GBS, paralytic rabies should be considered as an alternative diagnosis, especially in regions where rabies is endemic, and early MRI of the brain and spine should be considered for the antemortem diagnosis of paralytic rabies.

Keyword

Paralytic rabies; Guillain-Barre Syndrome; Magnetic resonance imaging

Figure

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  Fig. 1. Magnetic resonance imaging brain-T2 weighted axial image at the level of midbrain shows hyperintensity along the substantia nigra, mesial temporal structures, and left parieto-occipital region involving cortex and underlying white matter (A), at a higher level shows bilateral parieto-occipital hyperintensities involving the cortex and underlying white matter; subtle hyperintensities are also noted in centrum semiovale bilaterally (B). On fluid-attenuated inversion recovery axial images, the hyperintensities are better appreciated in the similar regions and additional hyperintensities are noted in the optic tracts and hypothalamic region (C) and bilateral frontal region (not apparent on T2) (D). Pathological changes are highlighted by vertical arrows.

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  Fig. 2. Magnetic resonance imaging spine-T2 weighted sagittal image of the conus-cauda region shows subtle hyperintense signal changes in the conus and nerve roots of the cauda are slightly thickened (A). Post-contrast T1 fat saturation image shows intense enhancement of the cauda nerve roots along with conus enhancement (B) and nerve roots enhancement noted at parasagittal level (C), as indicated by horizontal arrows.

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