A 40-year-old man who farmed in Mexico and raised dogs as a hobby presented with dysphagia, hydrophobia, insomnia, anorexia, malaise, fever, and decreased strength and sensation in his dominant arm. After a repetitive three-hour history and physical examination, a tentative diagnosis of rabies was made in an atmosphere of patient denial followed by reluctance of hospital personnel to accept such a rare diagnosis. Upon confirmation of the diagnosis by the Center for Disease Control, Atlanta, the patient underwent aggressive therapy, including maximum respiratory support, anticonvulsants, steroids, pressors, hemodialysis and interferon treatment, but died on the 16th day following admission. This case is presented because of its rarity and to review the disease, clinical history, current therapy, and recent literature regarding emergency department differential diagnosis.