An ongoing dialogue on HIV/AIDS, infectious diseases,
January 21st, 2026
Rabies Is Terrifying — and the Challenge of Managing a Low Risk of a Dreadful Disease
Three case reports of human rabies recently appeared in the MMWR. Reading each one served as a reminder of just how horrifying this infection is when it strikes — which very fortunately is quite rare in our country.
Two cases were domestic and followed recognized direct bat exposures with no post-exposure preventive measures taken. Here are the exposure summaries:
Case 1: In July 2024, a Minnesota woman who lived alone reported to family members that a bat or bird had been trapped in her house for several days. After discovering a bat in the sink, she reportedly killed it with a hammer and disposed of it. A bite was not mentioned; however, the method reportedly used to kill the bat could have produced splatter resulting in inoculation of infectious nervous tissue onto broken skin or mucous membranes. In addition, family members reported that the patient wore a hearing aid, was a deep sleeper who used a continuous positive airway pressure machine, and routinely consumed alcohol, factors that might have reduced her awareness of having had direct bat contact.
Case 2: In October 2024, a woman living in California told family members that she had recently found a bat indoors at her worksite. Although the bat initially appeared to be dead, when she handled it with her bare hands, she felt movement and a possible bite. She discarded the bat, and in the absence of any apparent wound, did not consult a medical provider or public health officials, and the bat was not tested for rabies.
Symptom onset was 3 weeks after bat exposure in the first case and 1 month in the second. Both individuals died.
The discussion emphasized the importance of the CDC’s recommendation to give the rabies vaccine after any direct bat contact. North American bats are small, and bites might not be apparent, causing trivial injuries. This is especially critical when the patient has conditions that make them less likely to notice a bite, as in the first case. As a result, any direct contact with a bat should warrant preventive intervention.
The third case was imported, with the patient’s exposure in Haiti 7 months before clinical presentation. (You read that right.) A prolonged delay in diagnosis led to a large number of healthcare workers potentially exposed, though fortunately none developed rabies. After a 10-day hospitalization at one hospital, he was transferred to another where the diagnosis was ultimately confirmed; he died approximately 6 weeks after initial symptom onset.
Key to solving the origin of this case was the phylogenetic analysis of the patient’s rabies virus, which showed it derived from a strain known to be endemic in canines and wild mongooses in Haiti — and distinct from the bat variant most commonly identified in U.S. cases.
These cases serve as a reminder that rabies remains an almost universally fatal condition. A case report of a 15-year-old girl who survived has led to some adoption of the treatment she received — the “Milwaukee Protocol” — though there is debate about its specific effectiveness versus advances in the critical care of patients with coma. Regardless, even survivors often have serious neurological sequelae — this is a terrible disease.
The challenge for us clinicians here in the United States, with only a few cases reported annually, is to assess the risk of exposures in scenarios quite different from those outlined in these recent case reports. We’d all recommend post-exposure prophylaxis and vaccination for patients who directly handled a bat or were bitten by a dog in Haiti.
But what about the bat flying around the house, or in a garage, but with no apparent bite? Canada dropped recommending rabies preventive measures for that scenario, with no reported increase in rabies cases. Or a dog bite in a foreign country with an established rabies vaccine protocol for dogs?
Consider the following cases:
Case 1: A man awoke from a sound sleep to find a bat flying around his room. He opened his windows and left the room. He returned in an hour, and the bat was gone. There was no apparent contact with the bat.
Case 2: A 12-year-old boy sustained a dog bite from a neighbor’s dog while visiting family in rural Brazil. The bite occurred while they were playing with a tennis ball, breaking his skin and causing slight bleeding. The neighbors said the dog had received most of its scheduled rabies vaccines and had exhibited no abnormal behavior.
Go ahead and vote! And let’s hear your thoughts in the comments section!
(Image: Two Bats Flying, by Hokusai Katsushika, 1830. National Library of Congress.)
Paul E. Sax, MD
Associate Editor
NEJM Clinician
Biography | Disclosures & Summaries
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