The initial symptoms of human rabies are nonspecific and last 1 to 4 days: fever, malaise, headache, anorexia, nausea, sore throat, cough, and pain, or paresthesia at the bite site (80%). Subsequently, central nervous system involvement becomes apparent with restlessness and agitation, altered mental status, painful bulbar and peripheral muscular spasms, opisthotonos, and bulbar or focal motor paresis. Alternatively, in 20%, an ascending, symmetric, flaccid, and areflexic paralysis, comparable to the Landry-Guillain-Barré syndrome, may be seen. Hypersensitivity to sensory stimuli and hydrophobia may occur at this stage, with the latter resulting from the sight, sound, swallowing, or even mention of water. Progressively lucid and confused intervals may become interspersed, cholinergic abnormalities may manifest (hyperpyrexia, mydriasis, and increased lacrimation and salivation), and brainstem dysfunction (dysphagia, optic neuritis, and facial palsies) with hyperreflexia may occur. Extensor plantar responses may be positive. Common complications include adult respiratory distress syndrome, diabetes insipidus, syndrome of inappropriate secretion of antidiuretic hormone, hypovolemia, electrolyte abnormalities, pneumonia, and cardiogenic shock with hypotension and dysrhythmia from rabies myocarditis. Coma, convulsions, and apnea are the final manifestations of rabid death.