CONCEALED TRUTHS OF CORNEAL SMEAR

KARTHYKAYANI.T.P.Dch 1st year DEPARTMENT OF PICU

 HOW RELIABLE IS CORNEAL

SMEAR IN DIAGNOSIS OF RABIES?!?!?!?!

-A CASE FOR DISCUSSION.

 Jana 3/m

c/o inability to open mouth- 3 days c/o inability to take feeds- 3 days c/o difficulty in walking 3 days Treated as a case of tetanus -- 3 days H/o dog bite 3 months back Corneal smear was sent - positive for rabies.

 No H/o fever No H/s/o raised ICP No H/o Aerophobia/hydrophobia

 Admitted at ICH as tetanus Repeat corneal smear was sent

positive On day 2 he had protrusion of tongue which he was not able to retract. In view of need for ventilator support shifted to IMCU.

ON EXAMINATION

Child conscious Irritable Afebrile Trismus(+) Risus sardonicus(+) Jaw clenched(+)

Tongue -protruded(unable to retract) edematous,ulcerated,discolouration of tip(+) -Drooling of saliva(+)

 CNS-

hypertonia DTR-brisk B/L Plantar-flexor Other systems normal

INVESTIGATIONS
CPK-76 IU/L(10-100IU/L)
CT Brain-Normal study CORNEAL SMEAR-Positive for rabies virus ribo nucleoprotein by DFA test- twice

RFT,LFT,ELECTROLYTES,Ca,PNormal

TREATMENT
INJ Tetanus immunoglobulin INJ Tetanus toxoid IV Metrogyl 25ml iv tds IV Diazepam infusion at 8mg/kg/day T.chlorpromazine 12.5 mg bd

COURSE OF ILLNESS
Dental intervention sought. CSF,hair follicle,saliva - sent for RT-PCR reported negative.

ARV course started.

DISCUSSION-ANTEMORTEM DIAGNOSIS OF RABIES:

CDC GUIDELINES

Saliva CSF Serum Skin scrapings - nape of neck. Corneal smear is no longer used.

DIAGNOSTIC METHODS
Direct flourescent antibody test-

nuchal skin biopsy

RT-PCR,Real time PCR-

saliva, csf &skin biopsy as early as 2 days success rate more in early stages

Direct fluorescent antibody test

RT-PCR

 Antibody detection test-

FAVN,RFFIT,MNT IFA After 7 -10 days csf & serum Virus isolation techniques MIT,RTCIT saliva, throat swabs, swabs of the nasal mucosa& csf.

TESTS DFA on corneal smear DFA on skin biopsy

RT-PCR ON SALIVA REAL TIME PCR ON SALIVA

SPECIMEN CORNEAL SMEAR

NUCHAL SKIN SALIVA SALIVA

SPECIFICITY SENSITIVITY 90 30

100 100 100

50-70 50-70 70-80

CONCLUSION
Polymerase chain reaction-the

diagnostic

Repeat tests Corneal smear in diagnosis is

obsolete.

Carry home message

Interpret the lab reports

with clinical features

ACKNOWLEDGEMENT
We thank - The veterinary college - The following departments

Dental VPD Neurology