RABIES, TETANUS

& MALARIA REVIEWER

Mary Ann D. Lansang
Section of Infectious Diseases
The Medical City
6 September 2014
RABIES
Chaper 195, Harrison 18e
Rabies virus
Family: Rhabdoviridae
Genera that can cause human disease

Lyssavirus Vesiculovirus

Rabies virus:
single-strand RNA virus
Epidemiology
• Worldwide zoonotic disease:
• 55,000 deaths/year: ~31,000 in Asia (mostly
India), ~24,000 in Africa
• Endemic in the Philippines – among the top 10
countries with a rabies problem
• ~ 200 to 300 rabies cases per year

• Animal bites (WHO data):

• 2010: 226,220 (with 257 reported rabies
deaths)
• 2011: 328,459 (with 209 reported rabies deaths)
Animal vectors of rabies (Philippines):
• Dogs: 83% of human rabies cases
• Cats and other domestic animals: 17%
• Rats and bats do not transmit rabies to
humans (Philippines)
Choose the best answer:
The hydrophobia and aerophobia in
rabies is mainly the result of:
A. Binding of nicotinic acetylcholine
receptors on postsynaptic membranes
B. Fast axonal transport of virus to the spinal
cord
C. Neuronal death in the CNS
D. Brainstem dysfunction
Choose the best answer:
The hydrophobia and aerophobia in
rabies is mainly the result of:
A. Infection of astrocytes in the CNS (p.1612—
neurons rather than astrocytes)
B. Binding of nicotinic acetylcholine receptors on
postsynaptic membranes (at neuromuscular
junctions—p.1612)
C. Neuronal death in the CNS (p. 1612—little
evidence of neuronal death
D. Brainstem dysfunction (p. 1613—results in
painful contraction of the diaphragm & accessory
respiratory, laryngeal, pharyngeal muscles in
response to swallowing fluids or stimulation from a
draft of air)
Modified true or false:
Encephalitic rabies has the following
features:
A. Autonomic dysfunction
B. Fast and furious encephalitis
C. It is the more common neurologic form of
rabies
D. Muscle and facial weakness
Modified true or false:
Encephalitic rabies has the following
features:
A. Autonomic dysfunction T
B. Fast and furious encephalitis T
C. It is the more common neurologic form of
rabies T (80%)
D. Muscle and facial weakness (F—paralytic
form; 20%)

p. 1613
Pathogenetic events following peripheral
inoculation of rabies virus (Fig 195-2)
Choose the best answer:
The most characteristic pathologic finding
in rabies is:
A. Babes nodules
B. Degenerative neuronal changes
C. Negri bodies
D. Neuronophagia
Choose the best answer:
The most characteristic pathologic finding
in rabies is:
A. Babes nodules—microglial nodules can be
seen but not the distinguishing hallmark of
rabies (p. 1612)
B. Degenerative neuronal changes—
dysfunction rather than degeneration
C. Negri bodies—eosinophilic cytoplasmic
inclusions in brain neurons containing rabies
virus proteins and viral RNA
D. Neuronophagia—neuronal destruction by
phagocytes seen occasionally
Negri bodies
Modified true or false:
Management of rabies:
A. Rabies postexposure prophylaxis (PEP)
can effectively prevent rabies.
B. PEP includes local wound care and both
active and passive immunization.
C. Give rabies immune globulin IV and
rabies vaccine IM if a patient has been
bitten by a dog.
D. There is no effective treatment for rabies.
Modified true or false:
Management of rabies:
A. Rabies postexposure prophylaxis (PEP) can
effectively prevent rabies.--T
B. PEP includes local wound care and both
active and passive immunization.--T
C. Give rabies immune globulin IV and rabies
vaccine IM if a patient has been bitten by a
dog.—F (RIG at site of wound, or IM if
mucous membrane is affected area)
D. There is no effective treatment for rabies.—T

pp. 1615-6
PSMID-PFV 2012 Handbook:
Indications
• When person is bitten by a rabid person or
animal
• When the saliva or other potentially
infectious material such as neural tissue
has contaminated an open wound or
mucous membrane
• All persons exposed to rabid or suspect
rabid animals or persons
PSMID-PFV 2012 Handbook:
Categories of exposure to rabid animals/persons
• Category I: touching or feeding of animals or
persons, lick on intact skin
• Pre-exposure prophylaxis may be recommended
• Category II: nibbling of uncovered skin, minor
scratches or abrasion w/o bleeding, licks on
broken skin
• Post-exposure prophylaxis MUST be administered
• Category III: single or multiple transversal bits or
scratches, contamination of mucous membranes
with saliva; all Category II exposures on the head,
face or neck
• Post exposure prophylaxis MUST be administered
TETANUS
Chapter 140, Harrison 18e
Choose the best answer:
The neurotoxin that causes the clinical
manifestations of tetanus is:
A. Streptolysin
B. Synaptobrevin
C. Tetanolysin
D. Tetanospasmin
Choose the best answer:
The neurotoxin that causes the clinical
manifestations of tetanus is:
A. Streptolysin – related to tetanolysin but no role
in pathogenesis of tetanus
B. Synaptobrevin – aka VAMP2
• needed for presynaptic binding & release of
neurotransmitter. Tetanus toxin cleaves VAMP2, thus
preventing transmitter release and bloacking
inhibitory interneuron discharge
C. Tetanolysin – the other exotoxin produced by C.
tetani but no role in pathogenesis
D. Tetanospasmin – transported to motor nuclei
of the cranial nerves or ventral horns of the
spinal cord. p. 1197
Choose the best answer:
The diagnosis of tetanus is mainly by:

A. Culture of C. tetani from a wound

B. Measurement of antitetanus toxin level
C. Paroxysmal muscle spasms and
increased muscle tone
D. Electromyographic finding of intermittent
discharge of motor units
Choose the best answer:
The diagnosis of tetanus is mainly by:

A. Culture of C. tetani from a wound

B. Measurement of antitetanus toxin level
C. Paroxysmal muscle spasms and
increased muscle tone
D. Electromyographic finding of intermittent
discharge of motor units
The diagnosis of tetanus is CLINICAL.
 Wound management of immunocompetent persons

Characte- Clean, minor

ristic wounds All other wounds

History of Tdap TIG Tdap or TIG

TT/ # doses Td
Unknown or <3 Yes No Yes No
doses

3 or more No No No No
doses (yes, if > (yes if >
10 yrs 10 yrs
since last since last
Td) Td)
MALARIA
Chapter 210, Harrison 18e
Malaria transmission cycle
Modified true or false:
Pathogenetic events in malaria:

A. All Plasmodium species are capable of

sequestering RBCs containing mature forms of
the parasite in vital organs esp. the brain.
B. Cytoadherence, rosetting and agglutination are
central to the pathogenesis of falciparum
malaria.
C. P. vivax, P. ovale and P. malariae show a
marked predilection for for young RBCs, thus
producing a high level of parasitemia.
D. Hypnozoites are responsible for the relapses
observed in P. vivax and P. malariae malaria.
 Modified true or false:
Pathogenetic events in malaria:

A. All Plasmodium species are capable of sequestering RBCs

containing mature forms of the parasite in vital organs esp.
the brain. – F. Only P. falciparum (p. 1691)
B. Cytoadherence, rosetting and agglutination are central to
the pathogenesis of falciparum malaria. – T (p. 1691)
C. P. vivax, P. ovale and P. malariae show a marked
predilection for for young RBCs, thus producing a high level
of parasitemia. – F. (p. 1691)
P. vivax and P. ovale: young RBCs. P. malariae: old RBCs
A. Hypnozoites are responsible for the relapses observed in P.
vivax and P. malariae malaria. – F (p. 1688)
P. vivax and P. ovale have these intrahepatic dormant
forms.
Methods for the diagnosis of malaria
(p. 1696)
• Thick blood smear: sensitive (0.001% parasitemia); but
requires skill and experience
• Thin blood smear: rapid and inexpensive, but insensitive
(<0.05% parasitemia)
• PfHRP2 dipstick or card test: rapid; sensitivity
equivalent to thick smear but detects only P. falciparum;
remains positive for weeks after infection
• Plasmodium LDH dipstick or card test: rapid; sensitivity
similar to or slightly lower than thick films (0.001%
parasitemia. But more difficult than HRP2. Does not
speciate P. ovale, P. vivax and P. malariae
Choose the best answer:
Indicator/s of poor prognosis in severe
falciparum malaria:

A. Hemolysis
B. Parasitemia >100,000/ul
C. Respiratory alkalosis
D. Thrombocytosis
Choose the best answer:
Indicator/s of poor prognosis in severe
falciparum malaria:

A. Hemolysis
B. Parasitemia >100,000/ul (p.1692)
C. Respiratory alkalosis
D. Thrombocytosis
Treatment of malaria
___ 1. Drug of choice for P. A. Amodiaquine
vivax in Asia except in B. Artemether-
PNG & Indonesia lumefrantrine
___ 2. First-line drug for P. C. Artesunate IV
falciparum in the D. Chloroquine
Philippines
E. Primaquine
___ 3. Radical treatment
for P. vivax F. Quinine IV
___ 4. Severe falciparum G. Sulfadoxine-
malaria pyrimethamne
Treatment of malaria (p. 1698)
D 1. Drug of choice for P. A. Amodiaquine
vivax in Asia except in B. Artemether-
PNG & Indonesia lumefrantrine
B 2. First-line drug for P. C. Artesunate IV
falciparum in the D. Chloroquine
Philippines
E. Primaquine
E 3. Radical treatment
for P. vivax F. Quinine IV
F/C 4. Severe falciparum G. Sulfadoxine-
malaria pyrimethamne
Drugs used for malaria prophylaxis

In areas with: A. Atovaquone/proguan

____ 1. CQ or il (Malarone)
mefloquine-resistant Pf B. Chloroquine
____ 2. Predominantly C. Doxycycline
Pv species D. Mefloquine
____ 3. CQ-resistant E. Primaquine
Pf
Drugs used for malaria prophylaxis
(p. 1703)
In areas with: A. Atovaquone/proguan
A/D 1. CQ or il (Malarone)
mefloquine-resistant Pf B. Chloroquine
B/E 2. Predominantly C. Doxycycline
Pv species D. Mefloquine
D 3. CQ-resistant Pf E. Primaquine
APPLICATION
Modified true or false:
A 26M construction worker stepped on a nail whiile at
work, incurring a puncture wound at his right sole. 1
week later, he noticed difficulty opening his mouth
during speaking and swallowing, accompanied by back
spasms and pain. He was later brought to the ER
because of difficulty of breathing.
A. The diagnosis is clinical.
B. Metronidazole (400mg rectally or 500mg IV every 6h for
7 days) is the preferred antibiotic.
C. Antitoxin should be given early to deactivate any
circulating toxin.
D. The patient must be given a full primary course of
immunization even after acquiring the disease
Modified true or false:
A 26M construction worker stepped on a nail whiile at
work, incurring a puncture wound at his right sole. 1
week later, he noticed difficulty opening his mouth
during speaking and swallowing, accompanied by back
spasms and pain. He was later brought to the ER
because of difficulty of breathing.
A. The diagnosis is clinical.
B. Metronidazole (400mg rectally or 500mg IV every 6h for
7 days) is the preferred antibiotic.
C. Antitoxin should be given early to deactivate any
circulating toxin.
D. The patient must be given a full primary course of
immunization even after acquiring the disease
ALL TRUE
A 28F from Agusan del Sur was visiting her parents in Manila. On
her 3rd day in Manila, she developed high-grade fever and chills,
accompanied by frontal headaches. Her parents then noted that
she became increasingly drowsy over the next 2 days. On the
day of admission, she had a seizure, for which she was rushed to
the ER of The Medical City. The CBC showed speckled RBCs
and also ring-shaped forms within the RBCs. The best drug for
her is:
A. Doxycycline 3mg/kg qd x 7 days
B. Tetracycline 4mg/kg qid x 7 days
C. Quinine dihydrochloride 20mg salt/kg infused over 4
hours, then 10mg salt/kg infused over 2 hours, given
every 8 hrs
D. Artesunate 4mg/kg x 3 days plus amodiaquine 10mg/kg
x 3 days
A 28F from Agusan del Sur was visiting her parents in Manila. On
her 3rd day in Manila, she developed high-grade fever and chills,
accompanied by frontal headaches. Her parents then noted that
she became increasingly drowsy over the next 2 days. On the
day of admission, she had a seizure, for which she was rushed to
the ER of The Medical City. The CBC showed speckled RBCs
and also ring-shaped forms within the RBCs. The best drug for
her is:
A. Doxycycline 3mg/kg qd x 7 days
B. Tetracycline 4mg/kg qid x 7 days
C. Quinine dihydrochloride 20mg salt/kg infused over 4
hours, then 10mg salt/kg infused over 2 hours, given
every 8 hrs
D. Artesunate 4mg/kg x 3 days plus amodiaquine 10mg/kg
x 3 days