From acute flaccid paralysis (AFP)–Guillain–Barre Syndrome (GBS) and myelitis to progressive encephalopathy : acute disseminated encephalomyelitis (ADEM) atypical presentation of rabies following dog bite

Rabies encephalitis is a rare but severe complication following dog bites, particularly when appropriate prophylaxis is not administered. We present the case of a tween girl, the firstborn child of a non-consanguineous married couple, who developed neurological symptoms following a category three dog bite. The child had received four doses of the rabies vaccine but did not receive Rabies Immunoglobulin (RIG). She initially presented with progressive lower limb weakness followed by urinary retention, which eventually progressed to encephalopathy and dystonia. Initial diagnosis of Guillain-Barre syndrome, later as transverse myelitis, and acute disseminated encephalomyelitis was considered. Investigations, including cerebrospinal fluid (CSF) analysis, MRI, and Rabies virus neutralising antibody (RVNA) titers, led to a diagnosis of rabies encephalitis. This case emphasises the importance of clinical suspicion for rabies in children presenting with progressive lower limb weakness and the necessity of timely and complete post-exposure prophylaxis to prevent such rare but fatal outcomes.