title: Pneumomediastinum as initial presentation of paralytic rabies: a case report.
abstract: BACKGROUND
  Rabies is readily diagnosed when it presents as the classic furious form. Paralytic and atypical forms can pose significant problems in diagnosis. Catastrophic incidents included 7 organ transplant recipients who died of rabies recently in United States and Germany. Although rabies remains top in the lists of differential diagnosis of encephalitis in rabies endemic area, its complication may divert physicians from making a relevant management. We encountered an unusual case of paralytic rabies who presented with spontaneous pneumomediastinum.
  
  
  METHODS
  A young male presented with fever and dysphagia. There was a history of fluctuating consciousness and aerophobia but they were absent or could not be demonstrated at the time of admission. He exhibited subcutaneous chest wall emphysema and was found to have pneumomediastinum which resulted in surgical intervention. He developed paralysis followed by seizures during postoperative period. Diagnosis was confirmed by demonstration of rabies RNA in saliva during the preterminal phase and by the autopsy. Over 200 hospital staff subsequently received rabies postexposure prophylaxis.
  
  
  CONCLUSIONS
  Spontaneous pneumomediastinum can be a rare complication of rabies. It may lead clinicians to perform inappropriate treatment, particularly when phobic spasms are not present and agitation is not prominent. High level of awareness of rabies in any patient with confusion albeit subtle or with any obscure neurological presentations such as difficulty swallowing with no identifiable causes must be borne in mind.
authors.affiliation: Department of Emergency Medicine, King Chulalongkorn Hospital, Bangkok, Thailand. tornb2@hotmail.com
authors.forename: Pongtorn
authors.initials: P
authors.lastname: Kietdumrongwong
authors.forename: Thiravat
authors.initials: T
authors.lastname: Hemachudha
mesh_terms: D000293:Adolescent; D017809:Fatal Outcome; D006801:Humans; D008297:Male; D008478:Mediastinal Emphysema / Q000150:complications* / Q000175:diagnosis* / Q000473:pathology; D011818:Rabies / Q000150:complications* / Q000175:diagnosis* / Q000473:pathology