rabies is a fatal encephalomyelitis that transmitted most commonly through the bite of a rabid animal . tens of thousands of people around the world die every year from rabies , mostly in developing countries . in a few study , it was reported that in some individuals who received postexposure rabies vaccine , clinical features of rabies developed at the shorter time compare to individuals who were exposed , but not received the vaccine . in this article , we report an early death in a patient infected with rabies . a 67-year - old woman was admitted to the hospital with shortness of breath , headache , fatigue , anorexia and headache . the patient had a history of bite of her finger by jackal about 10 days before admission , and three doses of rabies vaccine ( imovax rabies , sanofi pasteur , iran ) was administered as an 1.0 ml injection in the deltoid muscle on days 0 , 3 , and 7 in conjunction with antirabies serum according to protocol , that is , prescribed by who expert committee on rabies . on admission , her vital signs were as follows : temperature 37c , pulse rate 100/min , blood pressure 210/110  mmhg , and respiration rate 26/min . admission laboratory values included prerenal azotemia ( blood urea nitrogen level of 54 meq / l and serum creatinine of 1.9 results of blood tests were as follows : white blood cell count , 19.0  10/dl with 86% neutrophils ; hemoglobin , 13.0 g / dl ; serum sodium , 143 mmol / l ; serum potassium , 3.4 mmol / l ; serum glucose , 232 mg / dl ; and serum calcium , 8.6 mg / dl ; serum phosphorus , 2.7 mg / dl ; prothrombin time and partial thromboplastin time were normal and procalcitonin were < 0.5 ng / ml . the initial clinical diagnosis was rabies and ceftriaxone , and acyclovir was initiated . moreover , sodium valproate , phenytoin , and clonazepam were administrated according to the neurological consultation . the third hour after admission , tachycardia , tachypnea , and sialorrhea were increased , blood pressure had dropped and cyanosis occurred in the distal parts of upper and lower extremities . the patient level of consciousness was decreased gradually , and myoclonus had started . in the 4 h of admission , the patient developed respiratory and cardiac arrest and were transferred to intensive care unit after intubation . on the 3 day of hospitalization , she died despite treatment . to confirm the diagnosis , there were many punctuate hemorrhages and multiple infarcts involving the cortex , basal ganglia , and hippocampus . an acute encephalomyelitis characterized by a lymphohistiocytic infiltrate , perivascular lymphocytic infiltration , and neuronophagia was reported in the cortical gray matter , along with patchy changes in the white matter . eosinophilic intracytoplasmic inclusion bodies indicative of negri bodies are present within purkinje cells , and larger neurons of the brainstem . rabies is a fatal viral disease of carnivorous animals , but warm - blooded animals , and human are believed to be susceptible and is spread by the bites of mammals . the importance of disease due to the high fatality rate , mortality and economic losses that can cause disease in animals , high vaccine cost . rabies is endemic in the wildlife of iran and infection frequently transmitted from wildlife hosts to domestic animals . rabies immune globulin and the first dose of rabies vaccine should be given as soon as possible after exposure since delays in initiating a postexposure prophylaxis reduce its effectiveness , and the disease is almost always fatal . rabies prophylaxis is very effective documented for correctly completed vaccination series in the usa since cell - purified vaccines have been utilized . however , in recent years , there have been doubts about the safety of rabies vaccines . it has been proposed that administration of rabies vaccine during symptomatic rabies could be ineffective , and there are concerns about the  early death  phenomenon reported in animals that develop rabies with shorter incubation period after rabies vaccine administration . early death could be developed during symptomatic rabies by rabies vaccine rabies or transfer of effector cells or antibodies , and cause dominant symptoms and earlier death . it has been shown that infection with replication - deficient rabies viruses , in some animals with a low level of rabies - induced antibody lead to earlier death compared with those without antibody . similarly , in humans exposed to rabies , individuals who received postexposure immunization develop clinical rabies with shorter incubation period than patients who did not receive the vaccination . this phenomenon can be transferred via spleen cells or plasma of vaccinated animals into infected recipients . it has been proposed that the immunity of the rabies virus during the active disease may lead to immune response convert from noncytopathic antibody - mediated clearance to antibody - dependent cytotoxicity . significant neuronal loss and demyelination may occur due to the extension of the immune response to the brain . andral in his study shows that lack of thymus in the mouse prevents early death , but the reduction of b lymphocytes with cyclophosphamide administration has not had any effect on this phenomenon . results show that the immune response to rabies has a dual role , sometimes favorably on survival but sometimes with amplification of the disease .
it was reported that in some individuals who received postexposure rabies vaccine , clinical features of rabies developed at the shorter time compared to individuals who were exposed , but not received the vaccine , which called  early death 
 phenomenon . 
 we reported an early death phenomenon in a 67-year - old woman who was bitten by a jackal , although receiving three dose of rabies vaccine . 
 results show that the immune response to rabies has a dual role , sometimes has a favorable effect on survival but sometimes amplification the disease .