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Rabies post-exposure management in a solid-organ transplant recipient — MSRA MCQ

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HardInfectious DiseasesRabies post-exposure management in a solid-organ transplant recipientMSRA

A 42-year-old woman presents to general practice 10 days after an unprovoked bite from an unowned dog while visiting India. The bite broke the skin and bled. She irrigated the wound immediately; it is now fully healed. The dog cannot be traced. She has never received rabies vaccine. She received a kidney transplant 18 months ago and remains on tacrolimus, mycophenolate mofetil and prednisolone. Your practice has rabies vaccine available but does not hold human rabies immunoglobulin (HRIG). Which is the most appropriate management today?

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Correct answer: C — Give the first rabies vaccine dose today, contact RIgS within 24 hours, and arrange HRIG up to 20 IU/kg with further vaccine doses on days 3, 7, 14 and 30 plus serology at day 30

Explanation lettering: B = shown as A · A = shown as B · E = shown as D · D = shown as E

This is a category 3 terrestrial-animal exposure because the dog bite broke the skin. India is a UKHSA high-risk country for rabies in terrestrial animals; therefore, category 3 exposure gives a red composite risk. Her ongoing immunosuppression following solid-organ transplantation places her in the severely immunosuppressed group, irrespective of the relatively low prednisolone dose. For immunosuppressed patients with amber or red exposure, UKHSA guidance specifies HRIG and a five-dose vaccine regimen on days 0, 3, 7, 14 and 30, with serological assessment at the day-30 dose. Day 0 is the day vaccine is first given, rather than the date of exposure. A healed wound would usually limit HRIG use, but this restriction does not apply to severely immunosuppressed patients. In primary care, where vaccine is available, the first dose should be given rather than awaiting specialist discussion; RIgS should then be contacted within 24 hours to complete assessment and arrange HRIG. A uses the immunocompetent red-risk four-dose schedule. B omits HRIG and uses the immunocompetent schedule. D omits required confirmation of vaccine response. E is the schedule for previously fully immunised people and is inappropriate here.

Reference: Rabies risks in terrestrial animals by country (Updated 1 May 2024) — https://www.gov.uk/government/publications/rabies-risks-by-country/rabies-risks-in-terrestrial-animals-by-country Guidelines on managing rabies post-exposure (January 2023) — https://assets.publishing.service.gov.uk/media/63ce5d4b8fa8f53fe29c7fbd/UKHSA-guidelines-on-rabies-post-exposure-treatment-January-2023.pdf Interim recommendations for human rabies immunoglobulin (HRIG) use (30 June 2025) — https://www.gov.uk/government/publications/rabies-post-exposure-prophylaxis-management-guidelines/interim-recommendations-for-human-rabies-immunoglobulin-hrig-use