Rabies is a viral disease that affects the central nervous system and is almost always fatal once symptoms appear. Rabies has one of the highest case fatality rates of any infectious disease – close to 100% according to the World Health Organization. This means that if rabies is not treated before symptoms start, the disease is essentially a death sentence.
How does rabies kill?
Rabies causes inflammation of the brain, called encephalitis. The rabies virus spreads through the nervous system, affecting the brain and spinal cord. As the virus spreads, it causes swelling and dysfunction in parts of the brain that are critical for normal functioning. This includes areas that control behavior, movements, and sensations. The swelling pushes against the brainstem, which controls vital functions like breathing, swallowing, heart rate and blood pressure. As the brainstem becomes impaired, it leads to respiratory failure, cardiac arrest, and death.
Death from rabies usually occurs within 7-10 days after the first symptoms appear. There are rare cases of people surviving longer, up to 6 weeks, but this is unusual. Once symptoms start, very few people survive the disease without intensive and immediate medical care. With modern intensive care, there are a small number of patients who have recovered even after having symptoms, but this is extremely rare.
What are the symptoms of rabies leading up to death?
The first symptoms of rabies are flu-like and can include:
- Fever
- Headache
- Nausea
- Vomiting
- General weakness or discomfort
Within a few days, the disease progresses to more serious neurological symptoms as the virus spreads through the nervous system to the brain. These can include:
- Insominia
- Confusion
- Agitation
- Hallucinations
- Paralysis
- Difficulty swallowing
- Muscle spasms
- Seizures
One characteristic symptom is hydrophobia, which is an intense fear of water. This occurs because attempts at drinking worsen painful spasms in the throat and larynx. The word “rabies” actually comes from the Latin for “madness”. Patients often have bouts of highly agitated behavior mixed with periods of calm.
In the final stages as death approaches, patients fall into a coma as the brain and brainstem become increasingly impaired by swelling. This leads to loss of sensation, paralysis, respiratory failure, and cardiac arrest.
What do rabies symptoms feel like?
Accounts from rabies survivors describe the early flu-like symptoms as feeling like a severe case of the flu. As the neurological symptoms worsen, patients describe pain, tingling, numbness, and burning sensations throughout the body. They experience terror, anxiety, confusion, hallucinations, and insomnia.
Swallowing spasms are extremely painful. Paralysis causes loss of sensation and weakness. In the final coma stages, patients may lose awareness although this is not always the case.
How quickly does rabies progress?
The speed of rabies progression varies, but once symptoms start, death usually occurs within 7-10 days. This table summarizes the typical progression:
| Stage | Timing | Symptoms |
|---|---|---|
| Incubation period | 2 weeks to several months after exposure | No symptoms |
| Prodrome | 2-10 days after first symptoms | Flu-like symptoms like fever, headache, nausea |
| Acute neurological phase | 2-7 days after prodrome | Hallucinations, agitation, paralysis, spasms, hydrophobia |
| Coma | 2-3 days before death | Loss of consciousness, paralysis |
The incubation period between exposure and first symptoms is usually 1-3 months, but can vary from less than a week to over a year in rare cases. Once the first symptoms appear, the disease typically progresses rapidly through the phases unless intensive medical treatment is immediately provided.
What are complications of rabies leading to death?
Complications from rabies that can lead to death include:
- Respiratory failure – Rabies causes paralysis of respiratory muscles and impairment of breathing centers in the brain. This leads to an inability to breathe adequately.
- Cardiac arrhythmias – Abnormal heart rhythms like tachycardia occur, which can progress to complete heart block and cardiac arrest.
- Hypotension – Blood pressure drops severely due to brainstem dysfunction, causing shock.
- Gastrointestinal dysfunction – Inability to swallow or intestinal motility disorders prevent proper feeding and hydration.
- Secondary infections – Immobility and compromised immune function can lead to pneumonia, urinary tract infections, or sepsis.
- Brain herniation – Severe brain swelling can cause the brain to shift downward in the skull, compressing vital areas like the brainstem.
Ultimately most rabies deaths occur due to complete shutdown of the respiratory center in the brainstem as it becomes inflamed and dysfunctional. Preserving breathing function for as long as possible is a major goal of palliative care in rabies patients.
What happens in the final 24 hours before death from rabies?
In the final 24 hours before death from rabies, patients typically fall into a coma as the brainstem loses function. Breathing becomes irregular and often requires intubation and mechanical ventilation. There may be episodes of breathing cessation requiring resuscitation. Blood pressure drops severely as the cardiovascular system fails. Patients are unresponsive and completely paralyzed. Death usually results from respiratory arrest or cardiac arrhythmia caused by brainstem dysfunction.
What palliative care options are available?
Since rabies is almost always fatal once symptoms start, a major focus of care is on comfort measures and preparing for death. Palliative care options include:
- Pain management with morphine or other strong analgesics
- Anti-anxiety medications to control agitation and restlessness
- Fluids and nutrition support if swallowing allows, otherwise IV fluids
- Suctioning of saliva to prevent choking
- Preventing bed sores from immobility
- Mechanical ventilation when breathing fails
- Medications to improve heart rhythm
- Reducing stimuli that trigger episodes of agitation
- Providing mental health and spiritual support to the patient and family
The goal is to maximize comfort and alleviate suffering as much as possible. Counseling on preparing for death is also an important aspect of end-of-life care in rabies patients.
What are the options for life support?
Life support measures may help prolong life briefly for rabies patients but are very unlikely to result in recovery. Options include:
- Mechanical ventilation – Used when breathing stops, but temporary and often inadequate as brain function declines.
- Cardiopulmonary resuscitation (CPR) – Chest compressions and defibrillation may restart the heart but heart function will remain compromised.
- IV fluids and nutrition – Can temporarily maintain hydration if the patient can no longer swallow.
- Medications – Paralytics, inotropes, antiarrhythmics may temporarily stabilize some symptoms.
If used, life support measures are typically just a bridge to allow family members more time to gather and gain closure. Patients require heavy sedation due to pain and agitation these interventions cause.
What happens after death from rabies?
After death from rabies, the body continues to harbor large amounts of virus. The rabies virus can survive for over 1 hour in respiratory secretions. For safety:
- The body should only be handled while wearing protective gowns, masks, and gloves.
- Autopsies require special precautions to avoid exposure.
- Embalming should not be done.
- The body should be cremated or buried promptly to destroy any virus.
Any equipment, materials, or surfaces exposed to the patient during care or after death should be thoroughly decontaminated to prevent transmission.
Grief counseling and follow-up may be recommended for family and caregivers, who often feel guilt and trauma after witnessing the severe neurological symptoms and suffering at the end stages.
Could rabies transmission occur after death?
Yes, rabies virus can still be transmitted from an infected patient even after death. The virus survives in the body, especially in the spinal cord and brain. Contact with respiratory secretions, cerebrospinal fluid, or neural tissue can lead to transmission long after death, even without direct biting. Precautions are essential during procedures:
- Handling of the body
- Preparing the remains
- Performing an autopsy
- Embalming
- Cremating or burying the body
To prevent transmission after death, the WHO recommends leaving the body completely undisturbed for several hours to allow the virus to degrade. Proper PPE should be worn during all procedures and any exposed materials must be sterilized. The body should be cremated or buried quickly according to local guidelines.
Conclusion
Rabies remains an almost universally fatal disease once symptoms develop. Death usually occurs within 7-10 days due to progressive neurological dysfunction leading to respiratory failure and cardiac arrest. Medical care focuses on comfort measures and life support is only a short-term bridge. Strict precautions must be taken during care and after death to avoid transmission from the virus that persists in the body. While rabies is rare in areas with good control programs, it continues to kill tens of thousands of people each year globally. Better awareness, animal control, and vaccination programs are critical to eliminate this devastating disease.