Clinical rabies prognosis — DTM&H MCQ

Correct answer: A — Near-certain death once clinical rabies has manifested

The correct answer is A, near-certain death once clinical rabies has manifested. UKHSA states that rabies is an acute viral infection that is almost invariably fatal once symptoms develop, and this boy already has classical furious rabies features (hydrophobia, aerophobia, agitation) six weeks after an unvaccinated dog bite to the face, a high-risk site with a short incubation period due to proximity to the central nervous system. Once the prodrome progresses to encephalitic disease, the virus has already disseminated within neurons and no intervention alters the outcome; management becomes palliative. This is precisely why UK and WHO policy emphasises immediate, adequate post-exposure prophylaxis (wound cleansing, vaccine, and immunoglobulin where indicated) before symptom onset, since after onset the case fatality rate approaches 100 percent. Why the other options are wrong: C. Full recovery with intensive antiviral therapy: no antiviral agent has proven efficacy against clinical rabies; supportive intensive care does not alter the near-universal fatal course. B. Recovery with neurological sequelae after Milwaukee protocol: the Milwaukee protocol (induced coma plus antivirals) has produced only a handful of anecdotal survivors worldwide with severe deficits, is not reproducible, and is not recommended or used as standard UK practice. E. Partial recovery with immunoglobulin therapy: rabies immunoglobulin is only useful as part of post-exposure prophylaxis before symptoms develop; once clinical disease is established it has no therapeutic benefit. D. Survival if intrathecal ribavirin given within 24 hours: intrathecal ribavirin has been trialled experimentally but has not shown reliable survival benefit and is not part of any recognised UK or WHO treatment protocol. Key point: once hydrophobia, aerophobia, or other encephalitic features of clinical rabies appear, the disease is essentially untreatable and fatal, making pre-exposure and prompt post-exposure prophylaxis the only effective interventions.

Reference: UKHSA, Rabies: risk assessment, post-exposure treatment, management, gov.uk collection (updated 2025), https://www.gov.uk/government/collections/rabies-risk-assessment-post-exposure-treatment-management