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Ask the Expert - Dermatitis Associated with Rabies Postexposure Prophylaxis

Q. A 40 year old male soldier recently returned from an overseas deployment and required post-exposure prophylaxis to prevent rabies.  He was exposed to animal saliva through broken skin approximately 6 months prior.  The day after the patient’s second dose of rabies vaccine, he noticed a localized, maculopapular, pruritic rash strictly isolated to his bilateral inguinal folds.  The rash has persisted for the past 3 days. 

He denies changes in the character, severity, or distribution of his rash.  He specifically denies urticaria, angioedema, malaise, or fever. He reports feeling well.   

He denies any adverse symptoms in close temporal association with either rabies immune globulin (HRIG) or his prior rabies vaccine doses.  He denies any history of prior adverse reactions in association with any other vaccines.  He questions whether he should receive his third dose of the rabies vaccine today. 

Should the patient continue postexposure prophylaxis?

A.  The short answer is “yes”, the patient should continue the prophylaxis!

Interestingly, the prescribing information specifically states “prophylaxis should not be interrupted or discontinued because of local or mild systemic adverse reactions to rabies vaccine” (http://www.fda.gov/downloads/BiologicsBloodVaccines/Vaccines/ApprovedProducts/UCM133484.pdf).

Dermatitis has been reported in association with both human rabies IG (HRIG) and the rabies vaccine. The differential diagnosis for a localized inguinal rash includes atopic dermatitis, psoriasis, tinea cruris, erythrasma, and intertrigo.  Once these are excluded, the situation requires a risk/benefit analysis and careful discussion with the patient.  It is possible that the patient’ dermatitis is related to either the HRIG or the prior rabies vaccines.  However, the localized distribution of the patient’s rash and lack of symptom progression argue against a systemic reaction to either the HRIG or rabies vaccine.

Given the patient’s known exposure to animal saliva, and unknown history of the animal(s) involved, he does have risk for rabies infection.  With the patient’s informed consent, he should cautiously continue the vaccine series

In August 2011, a United States soldier stationed in New York became ill approximately 3 months following his return from a deployment to Afghanistan.  Diagnostic testing confirmed rabies virus.  The Department of Defense and the Department of Veterans Affairs have initiated a collaborative effort to identify other soldiers who may have had an unreported rabies exposure. Contact tracing and exposure investigations are currently underway.

Rabies postexposure prophylaxis includes thorough cleansing of wound(s) with soap and water. If available, wounds should be irrigated with a virucidal agent. The ACIP currently recommends postexposure prophylaxis for immunocompetent patients with both HRIG and 4 doses of rabies vaccine.  HRIG should be thoroughly infiltrated in the area around and into the wounds. Any remaining volume should be injected intramuscularly at a site distant from vaccine administration. The postexposure vaccine schedule includes four 1mL doses of Human Diploid Cell Vaccine (HDCV) or Purified Chick Embryo Cell Vaccine (PCEC) on days 0, 3, 7 and 14. The first vaccine dose should be administered as soon as possible after exposure.

As contact tracings and exposure investigations by the Department of Defense and the Department of Veterans Affairs continue, physicians with expertise in immunology and vaccines may be called with questions regarding rabies postexposure prophylaxis management.

 

Information on Rabies can be found at the following site: http://www.cdc.gov/rabies/

State and Local Rabies Consultation Contacts may be found at the following site:

http://www.cdc.gov/rabies/resources/contacts.html

Information from the U.S. Department of Veterans Affairs may be found at the following site: http://www.publichealth.va.gov/exposures/rabies/index.asp

Prescribing information for HRIG may be found at the following site:

https://www.novartisvaccinesdirect.com/Rabavert/RabavertEfficacy

Prescribing information for the HDCV may be found at the following site: http://www.fda.gov/downloads/BiologicsBloodVaccines/Vaccines/ApprovedProducts/UCM133484.pdf

 
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