The symptoms started with a pain in her right arm. The patient, a 65-year-old Virginia woman, went to an urgent care center and got painkillers. There was no hint that she in fact was infected with the world’s deadliest virus and was already destined to die – the price for contact with a puppy in India.

Virginia health officials reported on her case Thursday, along with a warning from the Centers for Disease Control and Prevention about the risk of contact with dogs and other animals while traveling in many developing countries.

A litter of puppies shortly after being vaccinated by NGO Mission Rabies during a rabies vaccination campaign in Goa, India. The puppies were painted with a red dot to signify that they were vaccinated, which ensures that dogs do not get re-vaccinated during the campaign, and helps estimate the vaccination coverage when the campaign is finished. Ryan Wallace / CDC, Poxvirus and Rabies Branch

The patient had been on a seven-week-long yoga retreat in India just weeks before. “Tour members confirmed that the patient was bitten by a puppy outside her hotel in Rishikesh, India, and that the wound was washed with water, but no further treatment was administered,” Virginia’s state public health veterinarian, Dr. Julia Murphy, and colleagues wrote in their report.

"I don't believe that she was playing with the puppy, but the puppy was seen in the area and approached her," Murphy told NBC News.

The canine strain of rabies has been eliminated in the U.S. thanks to strict vaccination laws, but the virus is common in many parts of Africa, Asia and Latin America. Other strains still circulate in the U.S., and those strains can infect pets and people as well as wild animals. The virus kills 59,000 people a year globally, according to the CDC. The patient, who was not identified, was infected with a strain of rabies common in dogs in India.

Rabies virus is almost 100 percent fatal once symptoms start. It doesn’t usually show symptoms immediately, so the yoga aficionado traveled home and resumed her normal life without knowing she was infected. Her symptoms were vague at first, and as she sought care over the coming days, she potentially exposed dozens of other people to the virus.

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“On May 7 (2017), she was evaluated at hospital A with shortness of breath, anxiety, insomnia, and difficulty swallowing water. The patient expressed concern about exposure to a toxic substance,” Murphy’s team wrote.

“On the evening of May 8, the patient became progressively agitated and combative and was noted to be gasping for air when attempting to drink water. Hospital staff members questioned family about animal exposures, and the patient’s husband reported that she had been bitten on the right hand by a puppy approximately six weeks before symptom onset while touring in India,” the researchers wrote. The difficulty swallowing water, often called hydrophobia, is one of the classic signs of rabies.

Samples were sent to the CDC and rabies was confirmed within days, Murphy said.

With rabies, once symptoms begin, there is almost no hope of a cure. Only two people have ever survived rabies in the U.S., and just a handful globally, all of them treated using a complex approach called the Milwaukee protocol.

The patient’s family tried this approach, which involves a medically induced coma, but she did not improve and she died on May 21, 2017, after medical care was stopped.

Meanwhile, the health department was tracking down anyone who had been in contact with the patient to see if they needed rabies vaccines, including one person bitten by the patient during a medical procedure. In the end, 72 people who had cared for the patient were advised to get vaccinated. If people are vaccinated after they are exposed to rabies, such as through an animal bite, the vaccine is 100 percent effective in preventing illness if given before symptoms begin. It can take weeks and even rarely, months for symptoms to start showing up.

Person-to-person transmission of rabies has never been documented, except in the case of organ transplants, but it's a risk that is not worth taking, Murphy said.

The health team also tracked down everyone who had been on the same yoga retreat.

“Three tour members in addition to the patient reported direct contact with the same puppy; two were determined not to have been exposed to infectious materials. One, a North Carolina resident, reported having been bitten on the leg,” Murphy’s team wrote. The health department recommended vaccination for that woman.

In the end, all the vaccines cost $235,000, the department reported. The woman was the ninth to die in the U.S. from rabies acquired overseas since 2008.

It’s a reminder that rabies is a risk in much of the world, the health officials said.

“Travelers to India, which has the world’s largest incidence of dog-mediated human rabies deaths, are recommended to receive pre-travel rabies vaccination if they will be involved in outdoor activities (such as camping, hiking, biking, adventure travel, and caving) that put them at risk for animal bites,” Murphy’s team wrote. “In the case of the yoga retreat tour, given the extended length of the tour and the rural and community activities involved, pre-travel rabies vaccina­tion should have been considered.”

The World Health Organization says dogs are the main source of human rabies deaths. In the U.S., bats are the main source, although raccoons, foxes and other animals can transmit rabies.

“Every year, more than 15 million people worldwide receive a post-bite vaccination,” the WHO says.

How does rabies compare to other viruses? HIV is incurable but can be controlled with drugs. Ebola kills between 20 percent and 70 percent of victims, depending on the strain and what treatment patients get. Marburg virus, a relative of Ebola, can kill up to 90 percent of patients.