The diagnosis of rabies depends upon a high level of clinical suspicion and may not be considered in the prodrome unless the patient gives a history of being bitten. There is usually itching around the site of the bite. Vague prodromal symptoms such as headache, myalgia, and fatigue precede the onset of rabies encephalitis. The classical furious rabies, with characteristic hydrophobic spasms, can be mistaken for generalized tetanus. Drug intoxication can also be confused with rabies. In the absence of spasms or hydrophobia, rabies can be misdiagnosed as viral encephalitis, postinfectious encephalitis, tetanus, poliomyelitis, or vaccine reactions. Paralytic (dumb) rabies, which generally follows a slower course, consists of ascending flaccid paralysis, usually from the bite site, with loss of autonomic function but not sensation. It may be misdiagnosed as Guillain-Barre syndrome.

In unvaccinated individuals rabies antibody occurs from late in the first week, but its absence does not exclude rabies. In vaccinated individuals very high levels in the cerebrospinal fluid or blood may be helpful. A fluorescent antibody test on punch biopsies from the nape of the neck is rapid, sensitive, and specific in expert hands (Blenden et al. 1986). Rabies virus tissue culture takes several days; saliva, cerebrospinal fluid, tracheal aspirates, or throat swabs may be cultured. Definitive diagnosis is usually made at postmortem.

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