The Milwaukee Protocol is applied on a human rabies case in the USA

Human rabies cases are now almost unheard of in developed countries such as the United States. In the past decade, only 23 cases have been reported with 8 of these contracted outside the US.

A controversial treatment for Rabies Encephalitis is tried on a 6-year-old boy in Florida

Human rabies cases are now almost unheard of in developed countries such as the United States. In the past decade, only 23 cases have been reported with 8 of these contracted outside the US.

The start of 2018 was a devastating one for the Roque family in Florida, when their 6-year-old son, Ryker, was rushed to the emergency room after suffering from hallucinations and seizures a few days after he was bitten by a bat. Rabies is now extremely rare in the US, with as few as 3 cases reported in humans in 2015. Rabies encephalitis is almost always fatal once symptoms begin, and therapy is classically palliative. In Ryker’s case, however, his doctors were not ready to give up. With his parents' consent, they attempted a controversial experimental treatment known as the “Milwaukee Protocol”, named after the city where it was first successfully implemented in 2004.

The Milwaukee Protocol was developed by Rodney Willoughby Jr. and is a treatment used in rabies-infected human beings. It involves chemically inducing the patient into a coma, followed by the administration of antiviral drugs combined with ketamine and amantadine. The theory behind the treatment protocol is based on the notion that rabies pathology stems from the central nervous system's neurotransmitter dysfunction. It assumes that with suppressed brain activity, there would be minimal damage while the patient’s immune system has more time to fight off the infection on its own.

One of the successful cases of the protocol’s application includes that of Jeanna Giese, a teenager from Wisconsin who survived rabies without receiving the vaccine and was too late for the post-exposure prophylactic. Unfortunately, Ryker Roque’s treatment did not succeed and he died on January 13th, 2018.

A few statistics

According to the Milwaukee Protocol Rabies Registry, variations of the protocol have been applied to 35 patients and there were 3 minimally documented survivors. Among these are a female adult patient from Colombia, a male adult patient from Peru (who later died from non-rabies attributable complications), and a Brazilian boy. A recent 2017 study also reported 5 survivors out of 36 rabies patients treated with the Milwaukee Protocol. Although studies have claimed lower numbers of survival, Willoughby Jr. stated that they have had 18 survivors so far with most of them in Peru and 2 in the US (Milwaukee and California). The high failure rate has prompted a backlash by the infectious disease community where many have said that it should be abandoned.

Conclusion

Although the Milwaukee Protocol is not an ideal treatment due to its low success rate, high costs and ethical debates that surround it, it makes it an unlikely option for extensive use or widespread acceptance as an effective treatment. However, it is also the only treatment protocol that survivors have as a last resort to present day.

Sources
Agarwal AK. The ‘Milwaukee protocol’ (MP) hope does not succeed for rabies victim. Med J DY Patil Univ. 2017; 10:184-186.
Zeiler FA, Jackson AC. Critical appraisal of the Milwaukee protocol for rabies: this failed approach should be abandoned. Can J Neurol Sci. 2016; 43(1):44-51.
Aramburo A, Willoughby RE, Bollen AW, et al. Failure of the Milwaukee protocol in a child with rabies. Clinical Infectious Diseases. 2011; 53(6): 572-574.

Lampejo T, Bruce M, Teall A, et al. Caring for a patient with rabies: implications of the Milwaukee protocol for infection control and public health measures. J Hosp Infect. 2017; 96(4):385-391.

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