Health officials have linked a Virginia woman’s 2017 rabies death to a dog bite she suffered while on a yoga retreat in India. The unidentified 65-year-old began suffering from pain and paresthesia in her right arm while gardening on May 3, 2017, which was about six weeks after she returned from her trip, according to the Centers for Disease Control and Prevention (CDC).

The canine rabies virus variant has been eliminated from the U.S. since 2004, according to the CDC, but continues to afflict 122 countries and is a leading global cause of human fatalities.

According to the case report, her symptoms were first diagnosed as carpal tunnel syndrome at an urgent care facility, but the following day she began experiencing shortness of breath, anxiety, insomnia, anxiety and difficulty swallowing water. Blood tests came back negative for exposure to a toxic substance, and she was diagnosed with a panic attack and given lorazepam, which can be used to relieve anxiety.

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But the woman didn’t even make it out of the unidentified hospital’s parking lot before she was back in the emergency room for shortness of breath and claustrophobia. Again, she was diagnosed with a panic attack and given an additional dosage of lorazepam.

The following day she was rushed to another hospital via ambulance with chest discomfort, shortness of breath, progressive paresthesia and increased anxiety. Lab tests recorded elevated cardiac enzymes, but an emergency cardiac catheterization indicated normal coronary arteries, and other tests found lack of coordination.

According to the report’s authors, once she became agitated and staff noticed she was gasping for air while attempting to drink water, family members were questioned about any potential exposure to animals. Her husband revealed that she had been bitten on the right hand by a puppy six weeks prior while in India.

“According to the husband, the patient cleaned the wound with the help of the tour operator but did not seek further medical treatment,” the report’s authors said. “The patient had no record of a pre-travel health screening, did not receive rabies pre-exposure vaccination before the trip, nor had she ever been vaccinated against rabies.”

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On May 9, the woman was intubated and placed on a ventilator, with further exams suggesting that she was suffering from severe brain infection. On May 11, a rabies diagnosis was confirmed, and two days later medical personnel attempted the full Milwaukee protocol, which is an experimental treatment that has saved one recorded rabies patient, but failed in several others. The treatment failed, and several other methods proved futile, with the patient’s family deciding to end intervention on May 21, and her death occurring shortly after.

The case report notes that the woman’s death is the ninth recorded death in the U.S. from rabies acquired abroad since 2008, and highlights the importance of pre-travel health exams and consultations.