limbic signs dominate the clinical picture in the former whereas a paralysis of lower motor neuron type dominates the latter . the diagnosis of rabies is not difficult if it presents with classical symptoms of excitations or phobias . however , it poses a diagnostic challenge when presented as acute flaccid paralysis ( afp ) . we report a case of paralytic rabies following intradermal anti - rabies vaccine , following cat scratch . a 15-year - old girl was brought with the complaints of fever of 5 days , headache and vomiting of 4 days , weakness of bilateral lower limbs , followed by upper limbs , change in voice and nasal regurgitation of feeds since 2 days . gag reflex was absent with pooling of secretions and absence of movements of soft palate and uvula . power in bilateral upper and lower limbs was 1/5 ( medical research council grade ) . she was immunized with a complete course of intradermal cell culture anti - rabies vaccine first dose started on day 2 of cat scratch . updated thai red cross schedule ( 2 - 2 - 2 - 2 - 2 ) was used for intra dermal vaccination . cat scratch was not cleaned . provisional diagnosis of paralytic rabies was made on the basis of paralysis with history of cat scratch . although rare with the modern cell culture vaccines , the possibility of vaccine - induced gbs was also considered . laboratory investigations revealed normal complete blood counts , serum electrolytes , liver and kidney function tests . cerebrospinal fluid ( csf ) analysis showed 412 cells with 10% neutrophils and 90% lymphocytes with sugar of 62 mg / dl . rabies virus rna was detected in csf and skin biopsy samples by reverse transcription polymerase chain reaction . neutralizing antibodies to rabies virus were detected in both serum and csf by the rapid fluorescent focus inhibition test . conservative management was started , but rapid progression with respiratory paralysis occurred over the next 2 days . there was no improvement and the patient succumbed on the 10 day of onset of the disease . about 55,000 human deaths occur due to rabies annually worldwide ; about 36% of these deaths occur in india . the disease infects domestic and wild animals , and is spread to people through close contact with infected saliva via bites or scratches . there are two forms of human rabies : ( 1 ) the well - known encephalitic ( furious ) and ( 2 ) the paralytic ( dumb ) rabies . the encephalitic form starts with fever , malaise , pharyngitis , and paraesthesia at the site of the bite , followed by the classical neurological symptoms of hydrophobia , aerophobia , agitation , hypersalivation , and seizures . this is followed by paralysis and coma ; death is usually due to respiratory failure . the second clinical form of rabies , paralytic ( dumb ) or guillain - barre - like , is characterized by progressive paralysis without an initial furious phase . even though , the paralytic rabies is unfamiliar to health care providers , 20 - 30% of rabies victims present in this manner . paralytic rabies is more common after rabid vampire bat bites and in persons who have received post - exposure vaccination . studies conducted in the united states by the center for disease control and prevention have documented that a regimen of one dose of rig and five doses of the human diploid cell culture vaccine ( hdcv ) over a period of 28 days was safe and induced an excellent antibody response in all recipients . clinical trials with rabies vaccine adsorbed and purified chick embryo cell vaccine have also demonstrated immunogenicity equivalent to that of hdcv . many individuals did not receive immunoglobulin where indicated , and some of them received the vaccine in the gluteal region instead of in the deltoid . although our patient had grade iii cat scratch for which rig is strongly recommended , she only received the vaccine in the deltoid region without rig . neurological reactions following newer vaccine administration have been extremely rare . after millions of vaccinations worldwide , three guillain - barre type paralytic reactions have been described , and all cases recovered completely . rare findings in our case are paralytic rabies following cat scratch and development rabies after administration of intradermal rabies vaccine . the limitation of our report was that we were not able to do magnetic resonance imaging of brain and nerve conduction studies . paralytic rabies should be considered if any child presenting with afp with brain stem symptoms and signs , even if they had already received anti - rabies vaccination and also following cat scratch . most rapidly immunogenic vaccine regimen should be used in patients at high risk , especially if rig has not been given .