Rabies Situation Is Insane

0:00 JA is a 50 year old man, presenting to the emergency room,

0:05 with anxiety, hypersalivation, and paresthesia.

0:07 Para meaning deviation, like how it’s used in PARAnormal.

0:11 And -esthesia meaning feeling.

0:13 A deviated feeling.

0:14 In this case, he had a horrible burning sensation in his forearms.

0:18 But nothing was burned there.

0:20 He can’t speak to the admitting nurse.

0:21 He has a hard time forming words.

0:23 He’s foaming at the mouth.

0:25 His neck muscles are rigid.

0:26 And clearly, something is wrong with his brain.

0:28 For 15 years, JA had been taking an herbal supplement for general health.

0:33 These tablets fixed his breathing problems, he thought.

0:35 And he took these at least 3 times a week, every week.

0:39 3 years ago, JA presented into the emergency room because something was wrong.

0:43 He was dizzy, and constantly out of breath.

0:45 And a blood test found out why.

0:47 His kidneys had completely shut down.

0:49 This isn’t surprising given that supplement he had been taking for 12 years.

0:52 The active ingredient herb, is from a family called Aristolochiaceae.

0:56 Ancient herbal wisdom, may have known this to be a very take-sparingly remedy.

1:01 Or better yet, just topical.

1:03 Skin only.

1:03 You probably weren’t supposed to take it long term,

1:05 or even really put it inside of your body in the first place,

1:09 because this has aristolochic acid.

1:11 This is nephrotoxic.

1:12 Nephro referring to the kidneys, explaining why JA’s kidneys were shutting down.

1:17 Aristolochic acid inserts itself into kidney cell DNA.

1:21 It turns the kidneys into a stiff fibrous shell,

1:24 incapable of functioning normally, explaining JA’s kidney failure.

1:27 But doctors didn’t know that he had been taking this supplement.

1:30 He didn’t tell them that.

1:31 Because he didn’t think anything of it.

1:32 It was such a minor detail of his everyday life,

1:35 he never gave it a second thought.

1:38 Doctors start him on dialysis.

1:39 This is hooking him up to a machine so that it can filter his blood for him.

1:43 This will remove the wastes that should have been taken care of by his kidneys.

1:47 If those wastes build up in his body, they can rot his body from the inside,

1:51 and very quickly shut down his heart and end everything.

1:53 But this is a temporary fix while they wait for a kidney transplant.

1:57 He has to go to dialysis multiple times a week.

2:00 3 years pass.

2:01 JA’s day finally arrives.

2:02 A kidney is available.

2:04 In rural Idaho, a middle aged man, was found unresponsive in his bed.

2:08 His heart had stopped beating.

2:09 His family was able to find him

2:11 in time for paramedics to arrive and resuscitate him.

2:14 But it wasn’t in time to actually save him.

2:17 At hospital, he never regained consciousness.

2:19 He was declared brain dead.

2:21 On hospital day 5, that man was removed from life support.

2:24 His organs were recovered and prepared.

2:26 And his left kidney was determined to be a match for JA.

2:30 At a hospital in Ohio, the medical team prepares JA.

2:33 It’s time for the kidney transplant.

2:35 Just one kidney.

2:36 But it’ll be enough that he wont need dialysis anymore.

2:39 At least for now.

2:40 Surgery’s done, and JA seems to recover nicely.

2:43 The transplanted kidney is called a graft.

2:46 JA is the host.

2:47 The immune system attacks things that arent supposed to be in the body.

2:51 If JA just got a new organ,

2:53 then the immune system will think that that organ, isn’t supposed to be there.

2:57 The immune system will attack that organ and destroy it,

2:59 while setting off a massive inflammatory reaction

3:02 inside JA’s body if nothing is done.

3:05 This organ rejection is called graft versus host disease.

3:08 But, we can do something about this.

3:10 Medicines were given to suppress JA’s immune system.

3:14 Three of them do three different things: 1) First, steroids.

3:17 They decrease white blood cells.

3:19 They decrease signals that kick off the immune system.

3:22 2) Second, another specialized medicine goes into the white blood

3:25 cells and stops their genes from producing immune signal molecules.

3:29 3) Third, a final medicine stops white blood cells from replicating.

3:33 It doesn’t destroy them, it just stops them from becoming too numerous.

3:36 This ensures that that kidney has time to acclimate inside JA’s body.

3:40 That blood vessels can regrow to that kidney.

3:43 And that his body can recover well.

3:45 On the flipside, this triplet neuters the immune system and predisposes him

3:49 to infections including ones you’re not

3:51 supposed to have in immunocompetent people.

3:53 But everything seems to be great.

3:55 A few weeks pass.

3:56 JA is feeling excellent, and recovering well.

3:59 But 5 weeks after the transplant.

4:01 Something was wrong.

4:02 Hey, quick question.

4:03 Have you learned a couple things from this video so far?

4:06 If you have, and you aren’t subscribed yet,

4:08 I’d appreciate it if you did subscribe and come

4:10 back to see the video I publish next month too.

4:12 I make these videos for fun, and I do them to teach people about medicine,

4:16 and to show how we think in the hospital.

4:18 I’ve made, on average, 1 video a month, every month, since 2017.

4:22 It’s my funtime hobby, making them is the highlight of my day,

4:25 and I’m so happy to be able to share them with you.

4:27 I appreciate you.

4:28 One evening, JA felt a burning sensation in his elbows.

4:31 It would pulsate into a pins and needles feeling in his hands.

4:34 When he got up his from his chair,

4:36 a pain shot up his leg and he collapsed to the floor.

4:39 At the toilet, JA tried to urinate, but… he just couldn't.

4:42 The feeling was there.

4:43 The urge was present.

4:44 But it was like he was in a public

4:46 bathroom with a giant line waiting behind him,

4:48 and the pee fright was too intense.

4:49 He started becoming disoriented to time and place.

4:52 When everything started making sense again, he’d notice that he was shaking.

4:56 At his computer, JA had poured himself a glass of water to take his medicine.

5:01 When he tried to drink, he suddenly choked.

5:03 It just didn’t go down the right way for some reason.

5:06 On the floor, gasping for air.

5:08 Water had gotten into his lungs.

5:09 He couldnt stop coughing.

5:11 Any time he even brought a glass of water to his face,

5:14 he’d have an overwhelming gagging sensation.

5:16 When he’d force himself to sip the water, he would shake uncontrollably.

5:19 The water, cupped in his mouth would spill out and he’d gasp for air,

5:24 unable to swallow the water or breathe, until finally he’d spit it out.

5:27 He needed to drink the water,

5:29 because he needed to take his immunosuppressant medicines.

5:31 But finally, he just totally gave up and stopped taking them.

5:35 One morning JA was found on the floor in the bathroom, screaming and shaking.

5:38 His neck jerking in unnatural ways so shocking to his wife,

5:42 that she calls for 911, and he’s brought to the emergency room where we are now.

5:48 At examination, doctors find a JA with fever,

5:51 stiff neck, agitation and paresthesia.

5:53 The brain is involved.

5:55 The nerves are involved.

5:56 And fever indicates an inflammatory process.

5:59 So, if he’s on immunosuppressants because he’s 5 weeks post kidney transplant,

6:05 then, putting everything together, points to meningitis.

6:09 -itis meaning an inflammation of the meninges,

6:11 the membrane covering the brain and the spinal cord.

6:14 Neck stiffness is a telltale sign.

6:15 The fever is the immune system trying to react to a pathogen

6:19 that got through because the immune system was getting held down,

6:22 to protect his transplanted kidney.

6:24 There’s one way for them to tell if this is meningitis.

6:27 The spinal cord and brain are surrounded by cerebrospinal fluid, CSF.

6:31 In meningitis, this fluid will be infected.

6:35 It might have protein and sugar floating around in it.

6:38 Doctors stick a needle in his back to collect a sample of this fluid.

6:42 But there’s a problem.

6:43 It’ll take about a day to grow out

6:45 detectable amounts of bacteria or fungus from it.

6:47 If they wait for the results to come back before giving him treatment,

6:51 a whole day’s worth of pathogen could grow.

6:54 That can be life or death.

6:56 But there can be other signals.

6:57 When they look at the fluid, it wasn’t cloudy.

7:00 Analysis didn’t show abnormal amounts of protein, or glucose.

7:03 It all seemed normal.

7:04 An MRI shows that something is happening.

7:07 It’s not normal, but it’s also not clear what it is.

7:10 It does kinda look like it’d be a viral infection, if anything.

7:14 Given all this information,

7:16 JA is started on antiviral medicine and empiric antibiotics.

7:19 Doing nothing while all the evidence points to something, IS life threatening.

7:24 Especially at a time like this when every second counts.

7:28 But something else entirely was going on.

7:30 On the second day in the hospital,

7:32 JA was found in his bed, choking on his own spit.

7:35 When he tried to cough, he would choke again.

7:38 At times, he’d shake violently in bed.

7:40 But then, he became unresponsive.

7:41 Doctors sedate him and put a tube down his throat.

7:44 To protect his airway.

7:46 And so that a machine can breathe for him.

7:48 When they look at the test results

7:50 for the bacteria and fungus from his cerebrospinal fluid,

7:53 they found out, this isn’t meningitis.

7:55 So what is it?

7:57 Doctors had written problem list.

7:58 They need to reason out why each one is not the problem.

8:02 And figure out from there.

8:04 Now that it’s not meningitis, it narrows down the list.

8:07 JA’s problems started 7 days ago.

8:09 This pace is important.

8:11 If he deteriorated like this in 7 seconds instead of 7 days,

8:15 he’d have a completely different problem.

8:16 7 seconds usually means some kind of blood

8:19 vessel problem like a clot blocking flow.

8:21 Or a bleed.

8:22 If it took 7 years, that’s a different problem in the opposite direction.

8:26 It could be neurodegenerative like Amyotrophic Lateral Sclerosis, ALS.

8:30 Or it could be a tumor.

8:32 But the MRI didn’t show a tumor.

8:34 There was no brain bleed.

8:35 This means he has an infection, but which one?

8:38 Tetanus causes muscle spasms.

8:39 These can make it impossible to swallow.

8:42 But tetanus doesn’t usually cause an altered mental state.

8:45 Diphtheria is caused by a bacterial toxin

8:48 that strips off myelin sheath from nerves.

8:50 It can cause problems swallowing,

8:52 but, it also makes it so that patients have trouble moving their eyes.

8:56 Their tongue.

8:57 Their face can start to droop.

8:58 None of those happening to JA.

9:00 Botulism is also caused by a bacterial toxin.

9:03 But it paralyzes the patient.

9:05 JA isn’t paralyzed.

9:07 Leaving 1 final infection to be the problem.

9:11 Rabies is an infection.

9:13 It’s from a virus.

9:14 Patients are first incubated after contact with rabid animal saliva.

9:18 That saliva has to get into the body.

9:20 So it’s from a bite or a scratch that breaks skin.

9:23 And then the virus settles for weeks.

9:26 Then the prodrome appears.

9:27 Pro here meaning early,

9:29 and drome from Greek referring to road or path down which one is headed.

9:33 This the early set of symptoms that worsen

9:36 as the patient descends into the acute neurologic phase.

9:40 Followed by Coma, and then, the end.

9:43 JA’s extreme aversion to water dubbed as hydrophobia is unique to rabies.

9:47 The other infections don’t usually cause this.

9:50 His other symptoms were all consistent with rabies too.

9:53 But there’s a problem: JA never came into contact with any animals.

9:57 He didn’t have pets.

9:58 He didn’t go outdoors.

9:59 Prior to transplant, he was sitting in dialysis for several hours,

10:03 several days a week.

10:05 And post transplant, he didn’t leave the house either.

10:08 Human Rabies, is extremely rare in the whole United States.

10:11 Just 125 cases had been reported in the 58 years from 1960 to 2018.

10:17 So… how did he get it?

10:19 Doctors contacted the Ohio Department of Health and Centers for Disease Control.

10:23 Very quickly, JA’s saliva, his blood, his CSF,

10:26 and samples from his neck skin were collected and sent to the CDC.

10:31 Rabies virus RNA was detected in his saliva and his CSF, confirming rabies.

10:36 When they sequenced the viral genome, they determined,

10:39 the rabies JA had, was from a silver-haired bat.

10:43 But when public health officials interviewed JA’s family,

10:46 they confirmed JA never had contact with any bats.

10:49 Or any other animal.

10:51 So… where did the virus come from?

10:54 Health officials looked at JA’s medical record.

10:56 His only contact from the outside world,

10:58 that broke his skin, was the transplanted kidney.

11:01 They traced back to the kidney donor in Idaho.

11:04 They pulled up his medical record.

11:06 No mention of rabies.

11:07 But he was a middle aged man who just suddenly died in his bed.

11:12 Why did that happen?

11:14 Idaho Department of Health and Welfare went

11:16 to the donor family to interview them.

11:18 And this is where they found out everything.

11:22 In December 2024, just days before he suddenly died in bed,

11:25 the organ donor in Idaho suddenly became confused,

11:28 with difficulty swallowing and walking, hallucinations,

11:31 and, he had a stiff neck, just like JA did.

11:34 5 weeks before, in late October, the man was outside his house with a kitten.

11:39 A skunk had approached them.

11:40 Its body language was in a way, that it was going to attack.

11:43 The man kicked the skunk to protect the kitten.

11:46 But it fought back until, it fell unconscious.

11:49 But it had scratched the man’s shin in the encounter, and drew some blood.

11:53 The man was pretty sure it was only a scratch, not a bite.

11:56 But the fact that it broke skin is a cause for concern.

11:59 It’s just that he didnt know it at the time.

12:02 And this is what started this tragedy.

12:04 Rabid animals will hypersalivate.

12:05 Virus is in the saliva.

12:07 Either from a bite, or a scratch, because these animals lick their claws:

12:11 the infected saliva can make it into human bodies when skin is broken.

12:16 Rabies virus replicates in muscle cells at the site of inoculation.

12:20 At the neuromuscular junction, where nerves connect to muscles,

12:23 the virus gains access into the nerves.

12:26 They migrate a few inches every day until they reach

12:29 the spinal cord where they start moving towards the brain.

12:32 This period is the incubation and prodromal

12:34 stage where bad things start to happen.

12:37 In the spinal cord, virus moves very quickly.

12:40 It gets to the brain.

12:41 And then very quickly, it spreads out widely through the nerves.

12:45 In highly innervated places like the salivary glands,

12:48 viral replication explodes.

12:49 Viral shedding gets all over the body.

12:52 The damage that rabies physically does to the brain

12:55 appears mild when compared to other diseases.

12:57 At least from what we know, at the moment.

13:00 By the time the medical team did the brain MRI for JA, the diffuse,

13:04 inconclusive finding may have been rabies already there,

13:08 causing dysfunction rather than brain death.

13:11 And when rabies spreads,

13:12 should that person become an organ donor after it’s over,

13:16 that virus will make its way

13:18 into the organ recipient’s body, infecting them too.

13:21 The reason this is particularly scary is that neither the patient nor

13:24 the medical team knows rabies is even involved at all until it’s too late.

13:29 The donor, who was previously healthy,

13:31 died suddenly with nothing on their medical record.

13:34 By the time the organ recipient develops symptoms,

13:36 virus is in the brain, spread throughout the body,

13:39 and the medical team will have wasted time ruling out the most obvious problems.

13:43 Problems caused by complications post organ transplant.

13:47 This was a chain reaction of unfortunate

13:50 events culminating in the final disaster.

13:53 Health authorities tested a sample of what was left of the organ donor’s

13:58 right kidney and detected rabies virus RNA

14:00 consistent with the silver-haired bat rabies variant,

14:03 consistent with the one found in JA, explaining how JA got it.

14:09 How do you treat something like this?

14:11 Time matters.

14:12 When the kidney donor got the skunk scratch, he had just a window of days,

14:16 where he could have gotten it

14:18 checked out and received post-exposure prophylaxis.

14:20 Theres 2 medicines here.

14:21 The first is antibodies that neutralize the virus.

14:25 The second, tells the body to produce even more of those antibodies,

14:28 so that viruses that have already replicated can be neutralized,

14:31 and that the body can continue to neutralize viruses for years afterwards.

14:36 When health authorities tested serum samples from the organ donor

14:39 that were collected when he presented to the hospital before he died,

14:43 they found he didn’t have any rabies virus antibodies.

14:46 This confirms his family’s statement that he didn’t

14:49 seek out any treatment after the skunk encounter.

14:52 But it also tells us his body didn’t enough

14:55 time to, or wasn’t able to, react to this infection.

14:58 But JA is still alive right now.

15:01 Is there anything that can be done for him?

15:04 In the hospital, blood tests find that JA’s body has produced rabies antibodies.

15:10 However, by the time he presented to the emergency room,

15:13 his disease had become so advanced.

15:15 Virus had replicated all throughout his nervous system,

15:18 and the rest of his body.

15:19 It had come in from the transplanted kidney.

15:22 Traveled through nerves.

15:23 Got into his spinal cord.

15:24 And from there, reached his brain.

15:26 The nerves sending signals from his brainstem to his heart,

15:30 quickly becoming dysfunctional because of the virus.

15:33 His advanced presentation, conflated by a difficult diagnosis,

15:36 in a disease that doesn’t have much

15:39 treatment this late in the course of illness,

15:41 made it difficult for the medical to do much more outside of supportive care.

15:46 But JA’s case wasn’t the only exposure.

15:49 Public health officials found out:

15:51 multiple people received cornea tissue from the eye, from the donor from Idaho.

15:57 Three patients, one each from California, Idaho and New Mexico were recipients.

16:02 This too, can transmit rabies.

16:04 These patients were tracked down.

16:06 The grafts were removed.

16:08 And post-exposure prophylactic therapy were given to them.

16:11 A fourth patient in Missouri had a corneal transplant scheduled,

16:15 but luckily, health authorities were able to stop it in time.

16:19 The health care workers who came into contact with JA,

16:22 who came into contact with the Idaho donor,

16:24 and who came into contact with the 3 cornea

16:28 recipients were also identified and given post-exposure prophylactic therapy.

16:31 The unfortunate part about this situation,

16:33 is that it isn’t the first time it’s happened in the United States.

16:38 In 2004, doctors at a hospital in Texas

16:40 diagnosed 3 organ transplant patients who got encephalitis.

16:43 A fourth patient also was diagnosed after receiving

16:46 part of a blood vessel during a liver transplant.

16:50 All 4 patients became progressively obtunded and lapsed into coma

16:54 and then died within 50 days of their transplant.

16:56 At the time the patients expired, doctors were stumped.

16:59 When they did their diagnostic tests, everything was ruled out.

17:02 They asked the CDC and the Texas Department of State Health Services for help,

17:07 because, these all happened at the same place.

17:10 There could be some kind of outbreak happening.

17:13 And when investigators looked,

17:14 they found that the organ donor had contracted rabies.

17:19 When he died, there were no mentions of rabies in his medical record.

17:26 But they detected rabies virus RNA in his body when they tested it.

17:30 And the organ recipients who died,

17:33 had the exact same rabies virus RNA in their bodies too.

17:37 In countries where Rabies is more common,

17:40 this situation of infection from organ transplant is more well known.

17:44 And JA would have the same

17:47 experience as these other rabies-infected organ recipients.

17:50 On hospital day 7, his heart stopped beating.

17:53 Doctors rushed into his room to try to resuscitate him.

17:55 But no matter what medicines they gave him,

17:58 and the CPR, they weren’t able to resuscitate him.

18:02 At autopsy, his brain samples were sent to CDC.

18:05 Confirmation of his rabies diagnosis by the CDC

18:08 laboratory happened after he passed away.

18:10 By the time he presented to the emergency room,

18:12 the disease was so advanced and virus had spread so deep,

18:16 he only had a few days left.

18:19 Investigators sequenced the RNA they found in JA’s samples and found it was

18:23 from the same silver haired bat variant

18:25 as was found in the Idaho kidney donor’s body.

18:28 They determined that a bat infected the skunk.

18:30 The rabid skunk scratched the donor, infecting him.

18:33 And then his organ donation subsequently infected JA.

18:37 And JA, being someone post-transplant, didn’t go outside,

18:40 didn’t interact with animals, was on immunosuppressants,

18:43 could have had a variety of other, more obvious infections and related issues.

18:48 But instead, it was the one infection that no one was thinking of, at the time.

18:53 After his case was published in December 2025,

18:56 CDC had already been examining guidance on what

18:59 to do so this doesn’t happen again.

19:01 There isn’t anything standard right now, but they want to raise awareness,

19:05 especially in the situation where an organ

19:08 donor had acute encephalopathy when they died.

19:10 It’s really important for the medical team to gather a proper history.

19:15 So while they figure that part out, what can you do?

19:18 The first is, if you’re in America, don’t panic, cause this is rare.

19:22 But, if you are in a place where theres rabies susceptible animals:

19:25 Bats, raccoons, skunks, fox, coyote,

19:28 and if you’re in Asia or Africa, mostly dogs,

19:32 you want to make sure that you get post-exposure prophylaxis therapy.

19:36 This really even goes for something like

19:38 Americans who go camping in places where there

19:40 might be bats and you’re sleeping without

19:42 a tent or any covering over your entire body.

19:45 Rabies prophylaxis is a medical urgency, and not an emergency.

19:48 You have a few days to get it after any possible exposure.

19:52 But please keep in mind, it’s days.

19:55 It’s not months.

19:55 It’s not years.

19:56 It’s days.

19:57 And if you or a family member might be getting an organ,

20:00 you might want to want to ask if

20:02 they checked about the donor having acute encephalopathy

20:04 at the time just before they transitioned to the state

20:08 whereby they will give that organ to you.

20:10 Thanks so much for watching.

20:11 Take care of yourself.

20:13 And be well.