Rabies differential diagnosis: Difference between revisions

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{{Rabies}}
__NOTOC__
{{CMG}}
[[Image:Home_logo1.png|right|250px|link=https://www.wikidoc.org/index.php/Rabies]]
{{CMG}} {{AE}} {{MIR}}


==Overview==
==Overview==
The differential diagnosis for rabies deals with eliminating diseases with similar symptoms from the diagnosis. There are many viruses that can appear similar to rabies such as [[encephalitis]] and the [[herpes simplex virus]]. It is very important to rule out certain diseases such as [[echovirus]] and [[poliovirus]]. Rabies is a serious disease that needs to be treated quickly if someone is suspected to be infected with the virus.


==Differential diagnosis==
==Differentiating Rabies From Other Diseases==
The [[differential diagnosis]] in a case of suspected human rabies may initially include any cause of [[encephalitis]],
Rabies should be differentiated from other causes of [[headache]] and [[Loss of consciousness|decrease consciousness]]:
particularly infection with viruses such as [[herpesviridae|herpesviruses]], [[enteroviruses]], and [[arboviruses]] (e.g., [[West Nile virus]]). The most important viruses to rule out are [[herpes simplex virus]] type 1, [[varicella-zoster virus]], and (less commonly) enteroviruses, including [[coxsackie virus|coxsackievirus]]es, [[echovirus]]es, [[poliovirus]]es, and human [[enterovirus]]es 68 to 71. A specific diagnosis may be made by a variety of diagnostic techniques, including [[polymerase chain reaction]] (PCR) testing of [[cerebrospinal fluid]], [[cell culture#Viral culture methods|viral culture]], and [[serology]]. In addition, consideration should be given to the local [[epidemiology]] of [[encephalitis]] caused by arboviruses belonging to several [[taxonomy|taxonomic]] groups, including [[Eastern equine encephalitis virus|eastern]] and [[western equine encephalitis virus]]es, [[St. Louis encephalitis]] virus, [[Powassan virus]], the [[California encephalitis virus]] serogroup, and [[La Crosse virus]].


New causes of viral encephalitis are also possible, as was evidenced by the recent outbreak in Malaysia of some 300 cases of encephalitis (mortality rate, 40%) caused by [[Nipah virus]], a newly recognized [[paramyxovirus]]. Similarly, well-known viruses may be introduced into new locations, as is illustrated by the recent outbreak of encephalitis due to [[West Nile virus]] in the eastern United States. Epidemiologic factors (e.g., season, geographic location, and the patient’s age, travel history, and possible exposure to animal bites, rodents, and ticks) may help direct the diagnostic workup.
{|
|- style="background: #4479BA; color: #FFFFFF; text-align: center;"
! rowspan="2" |<small>Diseases</small>
! colspan="5" |<small>History and Physical
! colspan="2" |<small>Diagnostic tests</small>
! rowspan="2" |<small>Other Findings</small>
|- style="background: #4479BA; color: #FFFFFF; text-align: center;"
!Prodromal symptoms
!<small>Fever</small>
!<small>Headache</small>
!<small>LOC</small>
!<small>Neuro Onset</small>
!<small>Laboratory Findings</small>
!<small>Imaging preferance</small>
|-
! style="background: #DCDCDC; padding: 5px; text-align:center;" |Rabies infection<ref name="pmid8489675">{{cite journal |vauthors=Baevsky RH, Bartfield JM |title=Human rabies: a review |journal=Am J Emerg Med |volume=11 |issue=3 |pages=279–86 |year=1993 |pmid=8489675 |doi= |url=}}</ref>
| style="background: #F5F5F5; padding: 5px; text-align:center" | +
| style="background: #F5F5F5; padding: 5px; text-align:center" | +
| style="background: #F5F5F5; padding: 5px; text-align:center" | +
| style="background: #F5F5F5; padding: 5px; text-align:center" | +
| style="background: #F5F5F5; padding: 5px; text-align:center" |Insidious
| style="background: #F5F5F5; padding: 5px; text-align:center" |[[Antibody]] detection in serology
 
[[Skin biopsy]] of injured skin
| style="background: #F5F5F5; padding: 5px; text-align:center" |[[MRI]]
| style="background: #F5F5F5; padding: 5px; text-align:center" |[[Hydrophobia]], aerophobia, [[dysphagia]], and localized pain, [[weakness]] or [[paresthesias]]
|-
! style="background: #DCDCDC; padding: 5px; text-align:center;" |[[Meningitis]]<ref name="pmid23050153">{{cite journal |vauthors=Tacon CL, Flower O |title=Diagnosis and management of bacterial meningitis in the paediatric population: a review |journal=Emerg Med Int |volume=2012 |issue= |pages=320309 |year=2012 |pmid=23050153 |pmc=3461291 |doi=10.1155/2012/320309 |url=}}</ref><ref name="pmid16474042">{{cite journal |vauthors=Chadwick DR |title=Viral meningitis |journal=Br. Med. Bull. |volume=75-76 |issue= |pages=1–14 |year=2005 |pmid=16474042 |doi=10.1093/bmb/ldh057 |url=}}</ref>
| style="background: #F5F5F5; padding: 5px; text-align:center" | +
| style="background: #F5F5F5; padding: 5px; text-align:center" | +
| style="background: #F5F5F5; padding: 5px; text-align:center" | +
| style="background: #F5F5F5; padding: 5px; text-align:center" | -
| style="background: #F5F5F5; padding: 5px; text-align:center" |Sudden
| style="background: #F5F5F5; padding: 5px; text-align:center" | [[CSF]] analysis:
 
'''↑''' [[Leukocytes]]
 
'''↑''' [[Protein]]
 
↓ [[Glucose]]
| style="background: #F5F5F5; padding: 5px; text-align:center" |[[CT scan]]: First choice
 
MRI: Best choice
| style="background: #F5F5F5; padding: 5px; text-align:center" |[[Fever]], [[Neck rigidity|neck]], [[Neck rigidity|rigidity]]
|-
! style="background: #DCDCDC; padding: 5px; text-align:center;" |[[Encephalitis]]<ref name="pmid15804262">{{cite journal |vauthors=Steiner I, Budka H, Chaudhuri A, Koskiniemi M, Sainio K, Salonen O, Kennedy PG |title=Viral encephalitis: a review of diagnostic methods and guidelines for management |journal=Eur. J. Neurol. |volume=12 |issue=5 |pages=331–43 |year=2005 |pmid=15804262 |doi=10.1111/j.1468-1331.2005.01126.x |url=}}</ref>
| style="background: #F5F5F5; padding: 5px; text-align:center" | +
| style="background: #F5F5F5; padding: 5px; text-align:center" | +
| style="background: #F5F5F5; padding: 5px; text-align:center" | +
| style="background: #F5F5F5; padding: 5px; text-align:center" | +
| style="background: #F5F5F5; padding: 5px; text-align:center" |Sudden
| style="background: #F5F5F5; padding: 5px; text-align:center" |[[PCR]]
 
[[CSF analysis]] and culture reveal the responsible [[Micro-organisms|micro-organism]]
| style="background: #F5F5F5; padding: 5px; text-align:center" |[[MRI]]
| style="background: #F5F5F5; padding: 5px; text-align:center" |Accompany a [[meningoencephalitis]], [[seizures]], [[hemiparesis]], [[cranial nerve palsies]], [[photophobia]], [[nausea]]
|-
! style="background: #DCDCDC; padding: 5px; text-align:center;" |Autoimmune encephalitis<ref name="pmid26754777">{{cite journal |vauthors=Lancaster E |title=The Diagnosis and Treatment of Autoimmune Encephalitis |journal=J Clin Neurol |volume=12 |issue=1 |pages=1–13 |year=2016 |pmid=26754777 |pmc=4712273 |doi=10.3988/jcn.2016.12.1.1 |url=}}</ref>
| style="background: #F5F5F5; padding: 5px; text-align:center" | -
| style="background: #F5F5F5; padding: 5px; text-align:center" | +/-
| style="background: #F5F5F5; padding: 5px; text-align:center" | +
| style="background: #F5F5F5; padding: 5px; text-align:center" | +/-
| style="background: #F5F5F5; padding: 5px; text-align:center" |Insidious
| style="background: #F5F5F5; padding: 5px; text-align:center" |[[Autoantibodies]] present in both [[serum]] and [[CSF]]
| style="background: #F5F5F5; padding: 5px; text-align:center" |[[MRI]]
 
EEG
| style="background: #F5F5F5; padding: 5px; text-align:center" |Memory deficit, [[Dyskinesia|dyskinesias]], [[seizures]], [[autonomic instability]]
|-
! style="background: #DCDCDC; padding: 5px; text-align:center;" |[[Brain abscess|CNS abscess]]<ref name="pmid24174804">{{cite journal |vauthors=Alvis Miranda H, Castellar-Leones SM, Elzain MA, Moscote-Salazar LR |title=Brain abscess: Current management |journal=J Neurosci Rural Pract |volume=4 |issue=Suppl 1 |pages=S67–81 |year=2013 |pmid=24174804 |pmc=3808066 |doi=10.4103/0976-3147.116472 |url=}}</ref>
| style="background: #F5F5F5; padding: 5px; text-align:center" | +
| style="background: #F5F5F5; padding: 5px; text-align:center" | +
| style="background: #F5F5F5; padding: 5px; text-align:center" | +
| style="background: #F5F5F5; padding: 5px; text-align:center" | +
| style="background: #F5F5F5; padding: 5px; text-align:center" |Insidious
| style="background: #F5F5F5; padding: 5px; text-align:center" |[[CSF]] analysis:
 
[[Leukocytes|'''↑''' Leukocytes]]
 
'''↓''' [[Glucose]]
 
'''↑''' [[Protein]]
| style="background: #F5F5F5; padding: 5px; text-align:center" |[[MRI]] is more sensitive and specific
| style="background: #F5F5F5; padding: 5px; text-align:center" |High grade [[fever]], [[fatigue]],[[nausea]], [[vomiting]]
|-
! style="background: #DCDCDC; padding: 5px; text-align:center;" | [[Poliomyelitis]]<ref name="pmid19705014">{{cite journal |vauthors=Obregón R, Chitnis K, Morry C, Feek W, Bates J, Galway M, Ogden E |title=Achieving polio eradication: a review of health communication evidence and lessons learned in India and Pakistan |journal=Bull. World Health Organ. |volume=87 |issue=8 |pages=624–30 |year=2009 |pmid=19705014 |pmc=2733260 |doi= |url=}}</ref>
| style="background: #F5F5F5; padding: 5px; text-align:center" | +
| style="background: #F5F5F5; padding: 5px; text-align:center" | +
| style="background: #F5F5F5; padding: 5px; text-align:center" | +
| style="background: #F5F5F5; padding: 5px; text-align:center" | +
| style="background: #F5F5F5; padding: 5px; text-align:center" |Sudden
| style="background: #F5F5F5; padding: 5px; text-align:center" |[[PCR]] of [[CSF]]
| style="background: #F5F5F5; padding: 5px; text-align:center" |[[MRI]]
| style="background: #F5F5F5; padding: 5px; text-align:center" |Asymmetric [[paralysis]] following a flu-like syndrome
|-
! style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Neurosyphilis]]<ref name="pmid15548491">{{cite journal |vauthors=Timmermans M, Carr J |title=Neurosyphilis in the modern era |journal=J. Neurol. Neurosurg. Psychiatr. |volume=75 |issue=12 |pages=1727–30 |year=2004 |pmid=15548491 |pmc=1738873 |doi=10.1136/jnnp.2004.031922 |url=}}</ref>
| style="background: #F5F5F5; padding: 5px; text-align:center" | -
| style="background: #F5F5F5; padding: 5px; text-align:center" | -
| style="background: #F5F5F5; padding: 5px; text-align:center" | +
| style="background: #F5F5F5; padding: 5px; text-align:center" | +
| style="background: #F5F5F5; padding: 5px; text-align:center" |Insidious<nowiki/>
| style="background: #F5F5F5; padding: 5px; text-align:center" |[[CSF]] [[VDRL]]-specifc
[[CSF]] [[FTA-ABS|FTA-Ab]] -sensitive
| style="background: #F5F5F5; padding: 5px; text-align:center" |[[MRI]] & [[Lumbar puncture]]
| style="background: #F5F5F5; padding: 5px; text-align:center" |History of unprotected sex or multiple sexual partners, and [[genital ulcer]] ([[chancre]])
[[Blindness]], [[confusion]], [[depression]], abnormal [[gait]]
|-
! style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Tick paralysis]] ([[Dermacentor andersoni|Dermacentor tick]])<ref name="pmid18755381">{{cite journal |vauthors=Edlow JA, McGillicuddy DC |title=Tick paralysis |journal=Infect. Dis. Clin. North Am. |volume=22 |issue=3 |pages=397–413, vii |year=2008 |pmid=18755381 |doi=10.1016/j.idc.2008.03.005 |url=}}</ref>
| style="background: #F5F5F5; padding: 5px; text-align:center" | -
| style="background: #F5F5F5; padding: 5px; text-align:center" | -
| style="background: #F5F5F5; padding: 5px; text-align:center" | +/-
| style="background: #F5F5F5; padding: 5px; text-align:center" | +/-
| style="background: #F5F5F5; padding: 5px; text-align:center" |Insidious
| style="background: #F5F5F5; padding: 5px; text-align:center" | -
| style="background: #F5F5F5; padding: 5px; text-align:center" | -
| style="background: #F5F5F5; padding: 5px; text-align:center" |History of outdoor activity in Northeastern United States
Tick often still latched to the patient at presentation (often in head and neck area)
|-
! style="background: #DCDCDC; padding: 5px; text-align: center;" | [[Botulism]]<ref name="pmid15257512">{{cite journal |vauthors=Cherington M |title=Botulism: update and review |journal=Semin Neurol |volume=24 |issue=2 |pages=155–63 |year=2004 |pmid=15257512 |doi=10.1055/s-2004-830901 |url=}}</ref>
| style="background: #F5F5F5; padding: 5px; text-align:center" | -
| style="background: #F5F5F5; padding: 5px; text-align:center" | -
| style="background: #F5F5F5; padding: 5px; text-align:center" | -
| style="background: #F5F5F5; padding: 5px; text-align:center" | -
| style="background: #F5F5F5; padding: 5px; text-align:center" |Sudden
| style="background: #F5F5F5; padding: 5px; text-align:center" |[[Toxin]] test, blood, wound, or [[stool culture]]
| style="background: #F5F5F5; padding: 5px; text-align:center" | -
| style="background: #F5F5F5; padding: 5px; text-align:center" |[[Diplopia]], [[Hyporeflexia|Hyporeflexia,]] [[Hypotonia]], possible respiratory paralysis, [[Floppy baby syndrome]]
|-
! style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Tetrodotoxin|Tetrodotoxin poisoning]]<ref name="pmid17425946">{{cite journal |vauthors=Hwang DF, Noguchi T |title=Tetrodotoxin poisoning |journal=Adv. Food Nutr. Res. |volume=52 |issue= |pages=141–236 |year=2007 |pmid=17425946 |doi=10.1016/S1043-4526(06)52004-2 |url=}}</ref>
| style="background: #F5F5F5; padding: 5px; text-align:center" | -
| style="background: #F5F5F5; padding: 5px; text-align:center" | -
| style="background: #F5F5F5; padding: 5px; text-align:center" | +/-
| style="background: #F5F5F5; padding: 5px; text-align:center" | +/-
| style="background: #F5F5F5; padding: 5px; text-align:center" |Sudden
| style="background: #F5F5F5; padding: 5px; text-align:center" | -
| style="background: #F5F5F5; padding: 5px; text-align:center" | -
| style="background: #F5F5F5; padding: 5px; text-align:center" | History of consumption of puffer fish species
|-
! style="background: #DCDCDC; padding: 5px; text-align: center;" |Metabolic disturbances ([[electrolyte imbalance]], [[hypoglycemia]])<ref name="pmid3966331">{{cite journal |vauthors=Josephson MA, Kaul S, Hopkins J, Kvam D, Singh BN |title=Hemodynamic effects of intravenous flecainide relative to the level of ventricular function in patients with coronary artery disease |journal=Am. Heart J. |volume=109 |issue=1 |pages=41–5 |year=1985 |pmid=3966331 |doi= |url=}}</ref>
| style="background: #F5F5F5; padding: 5px; text-align:center" | -
| style="background: #F5F5F5; padding: 5px; text-align:center" | +/-
| style="background: #F5F5F5; padding: 5px; text-align:center" | -
| style="background: #F5F5F5; padding: 5px; text-align:center" | +
| style="background: #F5F5F5; padding: 5px; text-align:center" |Sudden
| style="background: #F5F5F5; padding: 5px; text-align:center" |[[Hypoglycemia]], [[Hyponatremia|hypo]] and [[hypernatremia]]
| style="background: #F5F5F5; padding: 5px; text-align:center" |[[MRI]]
| style="background: #F5F5F5; padding: 5px; text-align:center" |[[Confusion]], [[seizure]], [[Palpitation|palpitations]], [[sweating]], [[dizziness]], [[hypoglycemia]]
|-
! style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Electrolyte disturbance]]<ref name="pmid3043756">{{cite journal |vauthors=Marcelou-Kinti O, Velegraki-Abel A |title=[Resistance to amphotericin B and genotypic resistance to 5-fluorocytosine of serotypes A and B of Candida albicans] |language=French |journal=Therapie |volume=43 |issue=2 |pages=121–2 |year=1988 |pmid=3043756 |doi= |url=}}</ref>
| style="background: #F5F5F5; padding: 5px; text-align:center" | -
| style="background: #F5F5F5; padding: 5px; text-align:center" | -
| style="background: #F5F5F5; padding: 5px; text-align:center" | -
| style="background: #F5F5F5; padding: 5px; text-align:center" | +/-
| style="background: #F5F5F5; padding: 5px; text-align:center" |Insidious
| style="background: #F5F5F5; padding: 5px; text-align:center" | [[Hypocalcemia]], [[hypomagnesemia]], [[Hypokalemia|hypo-]] or [[hyperkalemia]]
| style="background: #F5F5F5; padding: 5px; text-align:center" |
| style="background: #F5F5F5; padding: 5px; text-align:center" |Possible [[arrhythmia]]
|-
! style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Drug toxicity]]/[[Neuroleptic malignant syndrome]]<ref name="pmid9735957">{{cite journal |vauthors=Pelonero AL, Levenson JL, Pandurangi AK |title=Neuroleptic malignant syndrome: a review |journal=Psychiatr Serv |volume=49 |issue=9 |pages=1163–72 |year=1998 |pmid=9735957 |doi=10.1176/ps.49.9.1163 |url=}}</ref>
| style="background: #F5F5F5; padding: 5px; text-align:center" | -
| style="background: #F5F5F5; padding: 5px; text-align:center" | +
| style="background: #F5F5F5; padding: 5px; text-align:center" | -
| style="background: #F5F5F5; padding: 5px; text-align:center" | +
| style="background: #F5F5F5; padding: 5px; text-align:center" |Sudden
| style="background: #F5F5F5; padding: 5px; text-align:center" |Elevated serum [[Creatine kinase|creatine kianse]]
 
[[Hypocalcemia]], [[hypomagnesemia]], [[Hyponatremia|hypo-]] and [[hypernatremia]], [[hyperkalemia]], and [[metabolic acidosis]]
| style="background: #F5F5F5; padding: 5px; text-align:center" |Generalized slow wave [[EEG]]
| style="background: #F5F5F5; padding: 5px; text-align:center" |Causative medications (eg, [[neuroleptics]], [[antiemetics]], concomitant [[lithium]]), dopaminergic withdrawal
Mental status change, rigidity, or [[dysautonomia]]
|-
! style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Organophosphate poisoning|Organophosphate toxicity]]<ref name="pmid3057326">{{cite journal |vauthors=Minton NA, Murray VS |title=A review of organophosphate poisoning |journal=Med Toxicol Adverse Drug Exp |volume=3 |issue=5 |pages=350–75 |year=1988 |pmid=3057326 |doi= |url=}}</ref>
| style="background: #F5F5F5; padding: 5px; text-align:center" | -
| style="background: #F5F5F5; padding: 5px; text-align:center" | -
| style="background: #F5F5F5; padding: 5px; text-align:center" | -
| style="background: #F5F5F5; padding: 5px; text-align:center" | +
| style="background: #F5F5F5; padding: 5px; text-align:center" |Sudden
| style="background: #F5F5F5; padding: 5px; text-align:center" | Clinical suspicion confirmed with [[RBC]] AchE activity
| style="background: #F5F5F5; padding: 5px; text-align:center" | -
| style="background: #F5F5F5; padding: 5px; text-align:center" |History of exposure to i[[Insecticide|nsecticide]] or living in farming environment with : [[Diarrhea]], [[Miosis]], [[Bradycardia]], [[Lacrimation]], [[Emesis]], [[Salivation]], [[Sweating]]
|-
! style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Stroke|Ischemic stroke]]<ref name="pmid20412000">{{cite journal |vauthors=Baldwin K, Orr S, Briand M, Piazza C, Veydt A, McCoy S |title=Acute ischemic stroke update |journal=Pharmacotherapy |volume=30 |issue=5 |pages=493–514 |year=2010 |pmid=20412000 |doi=10.1592/phco.30.5.493 |url=}}</ref>
| style="background: #F5F5F5; padding: 5px; text-align:center" | -
| style="background: #F5F5F5; padding: 5px; text-align:center" | -
| style="background: #F5F5F5; padding: 5px; text-align:center" | +/-
| style="background: #F5F5F5; padding: 5px; text-align:center" | +
| style="background: #F5F5F5; padding: 5px; text-align:center" |Sudden
| style="background: #F5F5F5; padding: 5px; text-align:center" | -
| style="background: #F5F5F5; padding: 5px; text-align:center" |[[MRI]] for ischemia
| style="background: #F5F5F5; padding: 5px; text-align:center" |Sudden unilateral motor and sensory deficit in a patient with a history of [[Atherosclerosis|atherosclero<nowiki/>tic]] risk factors ([[diabetes]], [[hypertension]], smoking) or [[Atrial fibrillation|atrial fibrillation]]
|-
! style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Hemorrhagic stroke]]<ref name="pmid3443867">{{cite journal |vauthors=Bullard CW |title=Issues in low-level radioactive waste management |journal=JAPCA |volume=37 |issue=11 |pages=1337–41 |year=1987 |pmid=3443867 |doi= |url=}}</ref>
| style="background: #F5F5F5; padding: 5px; text-align:center" | -
| style="background: #F5F5F5; padding: 5px; text-align:center" | -
| style="background: #F5F5F5; padding: 5px; text-align:center" | +
| style="background: #F5F5F5; padding: 5px; text-align:center" | +
| style="background: #F5F5F5; padding: 5px; text-align:center" |Sudden
| style="background: #F5F5F5; padding: 5px; text-align:center" | -
| style="background: #F5F5F5; padding: 5px; text-align:center" |[[CT scan]] without contrast
| style="background: #F5F5F5; padding: 5px; text-align:center" |[[Neck stiffness]]
|-
! style="background: #DCDCDC; padding: 5px; text-align:center;" |[[Subdural hematoma|Subdural hemorrhage]]<ref name="pmid16408582">{{cite journal |vauthors=Cenic A, Bhandari M, Reddy K |title=Management of chronic subdural hematoma: a national survey and literature review |journal=Can J Neurol Sci |volume=32 |issue=4 |pages=501–6 |year=2005 |pmid=16408582 |doi= |url=}}</ref>
| style="background: #F5F5F5; padding: 5px; text-align:center" | -
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| style="background: #F5F5F5; padding: 5px; text-align:center" | +
| style="background: #F5F5F5; padding: 5px; text-align:center" | +
| style="background: #F5F5F5; padding: 5px; text-align:center" |Sudden
| style="background: #F5F5F5; padding: 5px; text-align:center" |[[CSF analysis|CSF analysis:]]
Xanthochromia
| style="background: #F5F5F5; padding: 5px; text-align:center" |[[CT scan]] without contrast
| style="background: #F5F5F5; padding: 5px; text-align:center" |[[Confusion]], [[dizziness]], [[nausea]], [[vomiting]]
|-
! style="background: #DCDCDC; padding: 5px; text-align:center;" |[[Hypertensive encephalopathy]]<ref name="pmid12803657">{{cite journal |vauthors=Schwartz RB |title=Hyperperfusion encephalopathies: hypertensive encephalopathy and related conditions |journal=Neurologist |volume=8 |issue=1 |pages=22–34 |year=2002 |pmid=12803657 |doi= |url=}}</ref>
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| style="background: #F5F5F5; padding: 5px; text-align:center" | +
| style="background: #F5F5F5; padding: 5px; text-align:center" | +
| style="background: #F5F5F5; padding: 5px; text-align:center" |Sudden
| style="background: #F5F5F5; padding: 5px; text-align:center" | -
| style="background: #F5F5F5; padding: 5px; text-align:center" | -
| style="background: #F5F5F5; padding: 5px; text-align:center" |[[Delirium]], [[cortical blindness]], [[cerebral edema]], [[seizure]]
|-
! style="background: #DCDCDC; padding: 5px; text-align:center;" |[[Wernicke's encephalopathy|Wernicke’s encephalopathy]]<ref name="pmid26644959">{{cite journal |vauthors=Flynn A, Macaluso M, D'Empaire I, Troutman MM |title=Wernicke's Encephalopathy: Increasing Clinician Awareness of This Serious, Enigmatic, Yet Treatable Disease |journal=Prim Care Companion CNS Disord |volume=17 |issue=3 |pages= |year=2015 |pmid=26644959 |pmc=4578911 |doi=10.4088/PCC.14r01738 |url=}}</ref>
| style="background: #F5F5F5; padding: 5px; text-align:center" | -
| style="background: #F5F5F5; padding: 5px; text-align:center" | -
| style="background: #F5F5F5; padding: 5px; text-align:center" | -
| style="background: #F5F5F5; padding: 5px; text-align:center" | +
| style="background: #F5F5F5; padding: 5px; text-align:center" |Sudden
| style="background: #F5F5F5; padding: 5px; text-align:center" | -
| style="background: #F5F5F5; padding: 5px; text-align:center" | -
| style="background: #F5F5F5; padding: 5px; text-align:center" |[[Ophthalmoplegia]], [[confusion]]
|-
! style="background: #DCDCDC; padding: 5px; text-align:center" |[[Amyotrophic lateral sclerosis]]<ref name="pmid26629397">{{cite journal |vauthors=Zarei S, Carr K, Reiley L, Diaz K, Guerra O, Altamirano PF, Pagani W, Lodin D, Orozco G, Chinea A |title=A comprehensive review of amyotrophic lateral sclerosis |journal=Surg Neurol Int |volume=6 |issue= |pages=171 |year=2015 |pmid=26629397 |pmc=4653353 |doi=10.4103/2152-7806.169561 |url=}}</ref>
| style="background: #F5F5F5; padding: 5px; text-align:center" | -
| style="background: #F5F5F5; padding: 5px; text-align:center" | -
| style="background: #F5F5F5; padding: 5px; text-align:center" | +/-
| style="background: #F5F5F5; padding: 5px; text-align:center" | +/-
| style="background: #F5F5F5; padding: 5px; text-align:center" |Insidious
| style="background: #F5F5F5; padding: 5px; text-align:center" | Normal [[Lumbar puncture|LP]] (to rule out DDx)
| style="background: #F5F5F5; padding: 5px; text-align:center" |[[MRI]]
| style="background: #F5F5F5; padding: 5px; text-align:center" |Patient initially presents with [[upper motor neuron]] deficit ([[spasticity]]) followed by [[lower motor neuron]] deficit ([[flaccidity]])
|-
! style="background: #DCDCDC; padding: 5px; text-align:center;" |[[Diffuse gliomatosis]]<ref name="pmid23341100">{{cite journal |vauthors=Chen S, Tanaka S, Giannini C, Morris J, Yan ES, Buckner J, Lachance DH, Parney IF |title=Gliomatosis cerebri: clinical characteristics, management, and outcomes |journal=J. Neurooncol. |volume=112 |issue=2 |pages=267–75 |year=2013 |pmid=23341100 |pmc=3907195 |doi=10.1007/s11060-013-1058-x |url=}}</ref>
| style="background: #F5F5F5; padding: 5px; text-align:center" | -
| style="background: #F5F5F5; padding: 5px; text-align:center" | -
| style="background: #F5F5F5; padding: 5px; text-align:center" | +
| style="background: #F5F5F5; padding: 5px; text-align:center" | -
| style="background: #F5F5F5; padding: 5px; text-align:center" |Insidious
| style="background: #F5F5F5; padding: 5px; text-align:center" |[[Cancer]] specific molecular characteristics
Normal [[CSF]]
| style="background: #F5F5F5; padding: 5px; text-align:center" |[[MRI]] (expansile, T2 hyperintense lesion)
| style="background: #F5F5F5; padding: 5px; text-align:center" |[[Seizure|Seizures]], [[memory loss]], motor weakness, visual symptoms, language deficit, and cognitive and personality changes
|-
! style="background: #DCDCDC; padding: 5px; text-align:center;" |[[Brain tumor|Central nervous system lymphoma]]<ref name="pmid16547083">{{cite journal |vauthors=Wilne SH, Ferris RC, Nathwani A, Kennedy CR |title=The presenting features of brain tumours: a review of 200 cases |journal=Arch. Dis. Child. |volume=91 |issue=6 |pages=502–6 |year=2006 |pmid=16547083 |pmc=2082784 |doi=10.1136/adc.2005.090266 |url=}}</ref>
| style="background: #F5F5F5; padding: 5px; text-align:center" | +
| style="background: #F5F5F5; padding: 5px; text-align:center" | -
| style="background: #F5F5F5; padding: 5px; text-align:center" | +
| style="background: #F5F5F5; padding: 5px; text-align:center" | +/-
| style="background: #F5F5F5; padding: 5px; text-align:center" |Insidious
| style="background: #F5F5F5; padding: 5px; text-align:center" |[[CSF analysis|CSF cytology,]] [[flow cytometry]], and stereotactic [[brain biopsy]]
| style="background: #F5F5F5; padding: 5px; text-align:center" |[[MRI]] ([[parenchymal]] or [[leptomeningeal]] enhancement)
| style="background: #F5F5F5; padding: 5px; text-align:center" |Associated with [[immunodeficiency]]
 
Focal neurological deficits, [[Neuropsychiatric|neuropsychiatric symptoms]], signs of [[raised intracranial pressure]], [[Seizure|seizures]], and ocular symptoms
|-
|}
The most important differential diagnosis when it comes to the rabies presentations include meningitis and encephalitis. It is important to differentiate different rabies from each one of the causes of meningitis/encephalitis, which may differ based on the season of occurrence and the geographical region.
 
The most important viruses to rule out are:<ref name="pmid12881794">{{cite journal |vauthors=Romero JR, Newland JG |title=Viral meningitis and encephalitis: traditional and emerging viral agents |journal=Semin Pediatr Infect Dis |volume=14 |issue=2 |pages=72–82 |year=2003 |pmid=12881794 |doi=10.1053/spid.2003.127223 |url=}}</ref><ref name="pmid26633824">{{cite journal |vauthors=Xie Y, Tan Y, Chongsuvivatwong V, Wu X, Bi F, Hadler SC, Jiraphongsa C, Sornsrivichai V, Lin M, Quan Y |title=A Population-Based Acute Meningitis and Encephalitis Syndromes Surveillance in Guangxi, China, May 2007-June 2012 |journal=PLoS ONE |volume=10 |issue=12 |pages=e0144366 |year=2015 |pmid=26633824 |pmc=4669244 |doi=10.1371/journal.pone.0144366 |url=}}</ref>
*[[Herpes simplex virus]] type 1
*[[Varicella-zoster virus]]
*(Less commonly) [[Enterovirus]]es including:
**[[coxsackie virus|Coxsackievirus]]es
**[[Echovirus]]es
**[[Poliovirus]]es
**Human [[enterovirus]]es 68 to 71
In addition, consideration should be given to the local [[epidemiology]] of [[encephalitis]] caused by arboviruses belonging to several [[taxonomy|taxonomic]] groups, including:
*[[Eastern equine encephalitis virus]]es
*[[Western equine encephalitis virus]]es
*[[St. Louis encephalitis]] virus
*[[Powassan virus]]
*The [[California encephalitis virus]] serogroup
*[[La Crosse virus]]
New causes of viral encephalitis are also possible, as was evidenced by the recent outbreak in Malaysia of some 300 cases of [[encephalitis]] (mortality rate, 40%) caused by [[Nipah virus]], a newly recognized [[paramyxovirus]]. Similarly, well-known viruses may be introduced into new locations, as is illustrated by the recent outbreak of encephalitis due to [[West Nile virus]] in the eastern United States. Epidemiological factors (e.g., season, geographic location, and the patient’s age, travel history, and possible exposure to animal bites, rodents, and ticks) may help direct the diagnostic workup.


==References==
==References==
{{Reflist|2}}
{{Reflist|2}}
{{WH}}
{{WS}}
[[Category:Disease]]
[[Category:Viral diseases]]
[[Category:Mononegavirales]]
[[Category:Neurology]]
[[Category:Zoonoses]]
[[Category:Emergency medicine]]
[[Category:Intensive care medicine]]
[[Category:Infectious disease]]
[[Category:Medicine]]

Latest revision as of 23:56, 29 July 2020

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Mahshid Mir, M.D. [2]

Overview

The differential diagnosis for rabies deals with eliminating diseases with similar symptoms from the diagnosis. There are many viruses that can appear similar to rabies such as encephalitis and the herpes simplex virus. It is very important to rule out certain diseases such as echovirus and poliovirus. Rabies is a serious disease that needs to be treated quickly if someone is suspected to be infected with the virus.

Differentiating Rabies From Other Diseases

Rabies should be differentiated from other causes of headache and decrease consciousness:

Diseases History and Physical Diagnostic tests Other Findings
Prodromal symptoms Fever Headache LOC Neuro Onset Laboratory Findings Imaging preferance
Rabies infection[1] + + + + Insidious Antibody detection in serology

Skin biopsy of injured skin

MRI Hydrophobia, aerophobia, dysphagia, and localized pain, weakness or paresthesias
Meningitis[2][3] + + + - Sudden CSF analysis:

Leukocytes

Protein

Glucose

CT scan: First choice

MRI: Best choice

Fever, neck, rigidity
Encephalitis[4] + + + + Sudden PCR

CSF analysis and culture reveal the responsible micro-organism

MRI Accompany a meningoencephalitis, seizures, hemiparesis, cranial nerve palsies, photophobia, nausea
Autoimmune encephalitis[5] - +/- + +/- Insidious Autoantibodies present in both serum and CSF MRI

EEG

Memory deficit, dyskinesias, seizures, autonomic instability
CNS abscess[6] + + + + Insidious CSF analysis:

Leukocytes

Glucose

Protein

MRI is more sensitive and specific High grade fever, fatigue,nausea, vomiting
Poliomyelitis[7] + + + + Sudden PCR of CSF MRI Asymmetric paralysis following a flu-like syndrome
Neurosyphilis[8] - - + + Insidious CSF VDRL-specifc

CSF FTA-Ab -sensitive

MRI & Lumbar puncture History of unprotected sex or multiple sexual partners, and genital ulcer (chancre)

Blindness, confusion, depression, abnormal gait

Tick paralysis (Dermacentor tick)[9] - - +/- +/- Insidious - - History of outdoor activity in Northeastern United States

Tick often still latched to the patient at presentation (often in head and neck area)

Botulism[10] - - - - Sudden Toxin test, blood, wound, or stool culture - Diplopia, Hyporeflexia, Hypotonia, possible respiratory paralysis, Floppy baby syndrome
Tetrodotoxin poisoning[11] - - +/- +/- Sudden - - History of consumption of puffer fish species
Metabolic disturbances (electrolyte imbalance, hypoglycemia)[12] - +/- - + Sudden Hypoglycemia, hypo and hypernatremia MRI Confusion, seizure, palpitations, sweating, dizziness, hypoglycemia
Electrolyte disturbance[13] - - - +/- Insidious Hypocalcemia, hypomagnesemia, hypo- or hyperkalemia Possible arrhythmia
Drug toxicity/Neuroleptic malignant syndrome[14] - + - + Sudden Elevated serum creatine kianse

Hypocalcemia, hypomagnesemia, hypo- and hypernatremia, hyperkalemia, and metabolic acidosis

Generalized slow wave EEG Causative medications (eg, neuroleptics, antiemetics, concomitant lithium), dopaminergic withdrawal

Mental status change, rigidity, or dysautonomia

Organophosphate toxicity[15] - - - + Sudden Clinical suspicion confirmed with RBC AchE activity - History of exposure to insecticide or living in farming environment with : Diarrhea, Miosis, Bradycardia, Lacrimation, Emesis, Salivation, Sweating
Ischemic stroke[16] - - +/- + Sudden - MRI for ischemia Sudden unilateral motor and sensory deficit in a patient with a history of atherosclerotic risk factors (diabetes, hypertension, smoking) or atrial fibrillation
Hemorrhagic stroke[17] - - + + Sudden - CT scan without contrast Neck stiffness
Subdural hemorrhage[18] - - + + Sudden CSF analysis:

Xanthochromia

CT scan without contrast Confusion, dizziness, nausea, vomiting
Hypertensive encephalopathy[19] - - + + Sudden - - Delirium, cortical blindness, cerebral edema, seizure
Wernicke’s encephalopathy[20] - - - + Sudden - - Ophthalmoplegia, confusion
Amyotrophic lateral sclerosis[21] - - +/- +/- Insidious Normal LP (to rule out DDx) MRI Patient initially presents with upper motor neuron deficit (spasticity) followed by lower motor neuron deficit (flaccidity)
Diffuse gliomatosis[22] - - + - Insidious Cancer specific molecular characteristics

Normal CSF

MRI (expansile, T2 hyperintense lesion) Seizures, memory loss, motor weakness, visual symptoms, language deficit, and cognitive and personality changes
Central nervous system lymphoma[23] + - + +/- Insidious CSF cytology, flow cytometry, and stereotactic brain biopsy MRI (parenchymal or leptomeningeal enhancement) Associated with immunodeficiency

Focal neurological deficits, neuropsychiatric symptoms, signs of raised intracranial pressure, seizures, and ocular symptoms

The most important differential diagnosis when it comes to the rabies presentations include meningitis and encephalitis. It is important to differentiate different rabies from each one of the causes of meningitis/encephalitis, which may differ based on the season of occurrence and the geographical region.

The most important viruses to rule out are:[24][25]

In addition, consideration should be given to the local epidemiology of encephalitis caused by arboviruses belonging to several taxonomic groups, including:

New causes of viral encephalitis are also possible, as was evidenced by the recent outbreak in Malaysia of some 300 cases of encephalitis (mortality rate, 40%) caused by Nipah virus, a newly recognized paramyxovirus. Similarly, well-known viruses may be introduced into new locations, as is illustrated by the recent outbreak of encephalitis due to West Nile virus in the eastern United States. Epidemiological factors (e.g., season, geographic location, and the patient’s age, travel history, and possible exposure to animal bites, rodents, and ticks) may help direct the diagnostic workup.

References

  1. Baevsky RH, Bartfield JM (1993). "Human rabies: a review". Am J Emerg Med. 11 (3): 279–86. PMID 8489675.
  2. Tacon CL, Flower O (2012). "Diagnosis and management of bacterial meningitis in the paediatric population: a review". Emerg Med Int. 2012: 320309. doi:10.1155/2012/320309. PMC 3461291. PMID 23050153.
  3. Chadwick DR (2005). "Viral meningitis". Br. Med. Bull. 75-76: 1–14. doi:10.1093/bmb/ldh057. PMID 16474042.
  4. Steiner I, Budka H, Chaudhuri A, Koskiniemi M, Sainio K, Salonen O, Kennedy PG (2005). "Viral encephalitis: a review of diagnostic methods and guidelines for management". Eur. J. Neurol. 12 (5): 331–43. doi:10.1111/j.1468-1331.2005.01126.x. PMID 15804262.
  5. Lancaster E (2016). "The Diagnosis and Treatment of Autoimmune Encephalitis". J Clin Neurol. 12 (1): 1–13. doi:10.3988/jcn.2016.12.1.1. PMC 4712273. PMID 26754777.
  6. Alvis Miranda H, Castellar-Leones SM, Elzain MA, Moscote-Salazar LR (2013). "Brain abscess: Current management". J Neurosci Rural Pract. 4 (Suppl 1): S67–81. doi:10.4103/0976-3147.116472. PMC 3808066. PMID 24174804.
  7. Obregón R, Chitnis K, Morry C, Feek W, Bates J, Galway M, Ogden E (2009). "Achieving polio eradication: a review of health communication evidence and lessons learned in India and Pakistan". Bull. World Health Organ. 87 (8): 624–30. PMC 2733260. PMID 19705014.
  8. Timmermans M, Carr J (2004). "Neurosyphilis in the modern era". J. Neurol. Neurosurg. Psychiatr. 75 (12): 1727–30. doi:10.1136/jnnp.2004.031922. PMC 1738873. PMID 15548491.
  9. Edlow JA, McGillicuddy DC (2008). "Tick paralysis". Infect. Dis. Clin. North Am. 22 (3): 397–413, vii. doi:10.1016/j.idc.2008.03.005. PMID 18755381.
  10. Cherington M (2004). "Botulism: update and review". Semin Neurol. 24 (2): 155–63. doi:10.1055/s-2004-830901. PMID 15257512.
  11. Hwang DF, Noguchi T (2007). "Tetrodotoxin poisoning". Adv. Food Nutr. Res. 52: 141–236. doi:10.1016/S1043-4526(06)52004-2. PMID 17425946.
  12. Josephson MA, Kaul S, Hopkins J, Kvam D, Singh BN (1985). "Hemodynamic effects of intravenous flecainide relative to the level of ventricular function in patients with coronary artery disease". Am. Heart J. 109 (1): 41–5. PMID 3966331.
  13. Marcelou-Kinti O, Velegraki-Abel A (1988). "[Resistance to amphotericin B and genotypic resistance to 5-fluorocytosine of serotypes A and B of Candida albicans]". Therapie (in French). 43 (2): 121–2. PMID 3043756.
  14. Pelonero AL, Levenson JL, Pandurangi AK (1998). "Neuroleptic malignant syndrome: a review". Psychiatr Serv. 49 (9): 1163–72. doi:10.1176/ps.49.9.1163. PMID 9735957.
  15. Minton NA, Murray VS (1988). "A review of organophosphate poisoning". Med Toxicol Adverse Drug Exp. 3 (5): 350–75. PMID 3057326.
  16. Baldwin K, Orr S, Briand M, Piazza C, Veydt A, McCoy S (2010). "Acute ischemic stroke update". Pharmacotherapy. 30 (5): 493–514. doi:10.1592/phco.30.5.493. PMID 20412000.
  17. Bullard CW (1987). "Issues in low-level radioactive waste management". JAPCA. 37 (11): 1337–41. PMID 3443867.
  18. Cenic A, Bhandari M, Reddy K (2005). "Management of chronic subdural hematoma: a national survey and literature review". Can J Neurol Sci. 32 (4): 501–6. PMID 16408582.
  19. Schwartz RB (2002). "Hyperperfusion encephalopathies: hypertensive encephalopathy and related conditions". Neurologist. 8 (1): 22–34. PMID 12803657.
  20. Flynn A, Macaluso M, D'Empaire I, Troutman MM (2015). "Wernicke's Encephalopathy: Increasing Clinician Awareness of This Serious, Enigmatic, Yet Treatable Disease". Prim Care Companion CNS Disord. 17 (3). doi:10.4088/PCC.14r01738. PMC 4578911. PMID 26644959.
  21. Zarei S, Carr K, Reiley L, Diaz K, Guerra O, Altamirano PF, Pagani W, Lodin D, Orozco G, Chinea A (2015). "A comprehensive review of amyotrophic lateral sclerosis". Surg Neurol Int. 6: 171. doi:10.4103/2152-7806.169561. PMC 4653353. PMID 26629397.
  22. Chen S, Tanaka S, Giannini C, Morris J, Yan ES, Buckner J, Lachance DH, Parney IF (2013). "Gliomatosis cerebri: clinical characteristics, management, and outcomes". J. Neurooncol. 112 (2): 267–75. doi:10.1007/s11060-013-1058-x. PMC 3907195. PMID 23341100.
  23. Wilne SH, Ferris RC, Nathwani A, Kennedy CR (2006). "The presenting features of brain tumours: a review of 200 cases". Arch. Dis. Child. 91 (6): 502–6. doi:10.1136/adc.2005.090266. PMC 2082784. PMID 16547083.
  24. Romero JR, Newland JG (2003). "Viral meningitis and encephalitis: traditional and emerging viral agents". Semin Pediatr Infect Dis. 14 (2): 72–82. doi:10.1053/spid.2003.127223. PMID 12881794.
  25. Xie Y, Tan Y, Chongsuvivatwong V, Wu X, Bi F, Hadler SC, Jiraphongsa C, Sornsrivichai V, Lin M, Quan Y (2015). "A Population-Based Acute Meningitis and Encephalitis Syndromes Surveillance in Guangxi, China, May 2007-June 2012". PLoS ONE. 10 (12): e0144366. doi:10.1371/journal.pone.0144366. PMC 4669244. PMID 26633824.

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