Chikungunya Fever

Epidemiology

History

  • The Name “Chikungunya” is Derived from an African Word Which Means “Stooped Walk” or “That Which Bends Up”, Due to the Capacity of the Disease to Cause Incapacitating Arthralgias

Transmission/Virology

  • Chikungunya Virus is an Arbovirus (Arthropod-Borne Virus) (see Arboviruses, [[Arboviruses]])
    • Family Togaviridae
    • Genus Alphavirus
  • Routes of Transmission
    • Bite from Infected Mosquito (see Mosquito-Borne Illnesses, [[Mosquito-Borne Illnesses]])
      • Aedes Aegypti
        • Note: Aedes Mosquitoes Can Also Transmit Dengue Virus and Zika Virus (see Dengue Virus, [[Dengue Virus]] and Zika Virus, [[Zika Virus]])
      • Aedes Albopictus (Asian Tiger Mosquito)
    • Maternal-Fetal Transmission: rarely
    • Blood Product Transfusion: rarely
    • Organ Transplantation: rarely

Geographic Distribution (Centers for Disease Control and Prevention, Geographic Distribution or Chikungunya Virus) [LINK]

  • Outbreaks Prior to 2013
    • Africa (Multiple Countries)
    • Asia (Multiple Countries)
    • Europe (Italy, France)
    • Indian Ocean
    • Pacific Ocean (Cook Islands, Samoa, French Polynesia, etc)
  • Sites of Local Transmission After 2013: >1.7 million cases have been reported to the Pan American Health Organization from these affected areas
    • Caribbean (Multiple Countries)
    • South America (Multiple Countries)
    • United States

Diagnosis

Real-Time Reverse Transcriptase Polymerase Chain Reaction (rRT-PCR) for Chikungunya Virus

  • Diagnostic for Patients within 1-7 Days Following Onset of Symptoms: excellent sensitivity/specificity during the first 5 days of infection
    • Testing for Dengue Virus and Zika Virus Should Also Be Simultaneously Performed (see Dengue Virus, [[Dengue Virus]] and Zika Virus, [[Zika Virus]]): a single PCR test for all 3 infections is available from the CDC and other laboratories

Serology for Chikungunya Virus

  • Diagnostic for Patients ≥8 Days Following the Onset of Symptoms
    • Anti-Chikungunya IgM Antibodies (Detected by Direct ELISA) are Present Starting at About 5 Days (Range: 1-12 days) Following the Onset of Symptoms
      • Anti-Chikungunya IgM Antibodies Persist for Several Weeks-3 mos
    • Anti-Chikungunya IgG Antibodies Begin to Appear at About 2 wks Following the Onset of Symptoms
      • Anti-Chikungunya IgM Antibodies Persist for Years
  • Technique
    • Enzyme-Linked Immunosorbent Assay (ELISA)
    • Indirect Fluorescent Antibody (IFA)

Culture for Chikungunya Virus

  • Used Mainly in Research Settings
    • Sensitivity of Culture for Chikungunya Virus is High in Early Infection But Decreases 5 Days After the Onset of Illness
    • Identification of the Viral Strain Can Be Useful for Epidemiologic Purposes

Clinical Manifestations

Acute Chikungunya Fever

General Comments

  • Incubation Period: 3-7 days (1-14 days)
  • Disease Course
    • Clinical Disease Begins Abruptly with Fever and Malaise
    • Duration of Illness: 7-10 days
  • Distinction Between the Clinical Presentations of Zika Virus, Dengue Virus, and Chikungunya Virus (see Dengue Virus, [[Dengue Virus]] and Chikungunya Fever, [[Chikungunya Fever]]) (Centers for Disease Control and Prevention, “Zika Virus-What Clinicians Need to Know?” Clinician Outreach and Communication Activity Call 1/26/16) [LINK]

Cardiovascular Manifestations

  • Myocarditis (see Myocarditis, [[Myocarditis]])
    • Epidemiology: may occur in some cases

Dermatologic Manifestations

  • Macular or Maculopapular Rash (see Macules, [[Macules]] and Papules, [[Papules]])
    • Epidemiology
      • Skin Involvement Occurs in 40-75% of Cases
      • Rash Appears ≥3 Days After Onset of Illness and Lasts 3-7 Days
      • Rash May Be Macular or Maculopapular: usually starting on extremities and trunk, spreading to face
      • Rash May Be Patchy or Diffuse
      • Pruritus Occurs in 25-50% of Cases
  • Bullae (see Vesicular-Bullous-Pustular Skin Lesions, [[Vesicular-Bullous-Pustular Skin Lesions]])
    • Epidemiology: occur in some cases (mostly in children)
  • Hyperpigmentation (see Hyperpigmentation, [[Hyperpigmentation]])
    • Epidemiology: occur in some cases
  • Skin Necrosis of the Nose
    • Epidemiology: case reports

Gastrointestinal Manifestations

  • General Comments: occur in some cases
  • Transaminitis (see Elevated Liver Function Tests, [[Elevated Liver Function Tests]])
    • Epidemiology: may occur

Hematologic Manifestations

  • Lymphadenopathy (see Lymphadenopathy, [[Lymphadenopathy]])
    • Epidemiology: may occur in some cases
    • Clinical: usually cervical
  • Lymphopenia
    • Epidemiology: may occur in some cases
  • Thrombocytopenia (see Thrombocytopenia, [[Thrombocytopenia]])
    • Epidemiology: may occur in some cases

Neurologic Manifestations

  • Acute Flaccid Paralysis (see xxxx, [[xxxx]])
    • Epidemiology: may occur in some cases
  • Cranial Nerve Palsies
    • Epidemiology: may occur in some cases
  • Guillain-Barre Syndrome (see Guillain-Barre Syndrome, [[Guillain-Barre Syndrome]])
    • Epidemiology: may occur in some cases
  • Headache (see Headache, [[Headache]])
    • Epidemiology: common
  • Meningoencephalitis (see Meningitis, [[Meningitis]] and Encephalitis, [[Encephalitis]])
    • Epidemiology: may occur in some cases
  • Myelitis (see Transverse Myelitis, [[Transverse Myelitis]])
    • Epidemiology: may occur in some cases

Ophthalmologic Manifestations

  • Conjunctivititis (see Conjunctivitis, [[Conjunctivitis]])
    • Epidemiology: may occur in some cases (Ophthalmology, 2008) [MEDLINE]
  • Other Ophthalmologic Manifestations: may occur in some cases
    • Iridocyclitis
    • Retinitis
    • Episcleritis
    • Macular Choroiditis
    • Uveitis (see Uveitis, [[Uveitis]])

Otolaryngologic Manifestations

  • Sensorineural Hearing Loss (see Hearing Loss, [[Hearing Loss]])
    • Epidemiology: may occur in some cases

Pulmonary Manifestations

  • Respiratory Failure (see Respiratory Failure, [[Respiratory Failure]])
    • Epidemiology: may occur in some cases

Renal Manifestations

  • Acute Kidney Injury (AKI) (see Acute Kidney Injury, [[Acute Kidney Injury]])
    • Epidemiology: may occur in some cases

Rheumatologic Manifestations

  • Bilateral Symmetric Polyarthralgias (see Arthralgias, [[Arthralgias]])
    • Epidemiology: begins 2-5 days after the onset of fever
    • Clinical
      • Usually Involve Multiple Joints (Distal > Proximal)
      • Pain May Be Severe and Disabling
      • Hands Involvement: 50-76% of cases
      • Wrist Involvement: 29-81% of cases
      • Ankle Involvement: 41-68% of cases
      • Axial Skeletal Involvement: 34-52% of cases
      • Periarticular Edema: occurs in 32-95% of cases
      • Large Joint Effusions: occur in 15% of cases
  • Myalgias (see Myalgias, [[Myalgias]])
  • Chondritis of External Ear
    • Epidemiology: may occur in some cases

Other Manifestations

  • Facial Puffiness
  • Fever (see Fever, [[Fever]])
    • Clinical: fever may be >39 degrees C

Persistent/Relapsed Chikungunya Fever

Rheumatologic Manifestations

  • Arthritis/Arthralgias (see Arthritis, [[Arthritis]] and Arthralgias, [[Arthralgias]]): involving the fingers and toes
  • Carpal Tunnel Syndrome (see Carpal Tunnel Syndrome, [[Carpal Tunnel Syndrome]]): due to hypertrophic tenosynovitis
  • Cryoglobulinemia (see Cryoglobulinemia, [[Cryoglobulinemia]])
  • Raynaud’s Phenomenon (see Raynauds Phenomenon, [[Raynauds Phenomenon]]): may occur in the 2nd-3rd month after infection
  • Severe Tenosynovitis: involving the wrists, hands, and ankles

Neonatal Chikungunya Fever

  • General Comments
    • Disease Onset: within 3-7 days of delivery
  • Fever (see Fever, [[Fever]])
  • Poor Feeding
  • Rash
  • Peripheral Edema (see Peripheral Edema, [[Peripheral Edema]])
  • Thrombocytopenia (see Thrombocytopenia, [[Thrombocytopenia]]): present in 89% of cases
  • Neurologic Disease
    • Meningioencephalitis
    • Cerebral Edema
    • Intracranial Hemorrhage
  • Elevated Liver Function Tests (LFT’s) (see Elevated Liver Function Tests, [[Elevated Liver Function Tests]])
  • Elevated International Normalized Ratio/Prothrombin Time (see xxxx, [[xxxx]])

Prevention

Protection from Mosquito Bites

  • Clothing
  • Insect Repellant
  • Mosquito Netting
  • Staying Indoors

Mosquito Control

  • Eliminate Standing Water Sources

Treatment

Acute Chikungunya Fever

Supportive Care

  • Hydration
  • Analgesics: as required for pain
  • Avoid Systemic Glucocorticoids/Immunosuppression

Post-Acute Chikungunya Fever

  • General Comments: generally in the period between 1 mo-3 mos after infection
  • Analgesics: as required for pain
  • Medications to Treat Neuropathic Pain
    • Gabapentin (Neurontin) (see Gabapentin, [[Gabapentin]])
    • Pregabalin (Lyrica) (see Pregabalin, [[Pregabalin]])
  • Physical Therapy
  • Systemic Glucocorticoids (see Corticosteroids, [[Corticosteroids]])
    • Short Tapers of Systemic Corticosteroids (10 days): may be useful
    • Longer Course of Systemic Corticosteroids (1-2 mos): may be required in some cases

Persistent/Relapsed Chikungunya Fever

  • Analgesics: as required for pain
  • Methotrexate (see Methotrexate, [[Methotrexate]]): may be required in some cases with persistent symptoms >3 mos

Chronic Chikungunya Fever


Prognosis

  • Deaths Have Been Reported During Outbreaks (Euro Surveill, 2006) [MEDLINE]

References

  • Chikungunya outbreak in Reunion: epidemiology and surveillance, 2005 to early January 2006. Euro Surveill. 2006;11(2):E060202.3. Epub 2006 Feb 2 [MEDLINE]
  • Ocular manifestations associated with chikungunya. Ophthalmology. 2008;115(2):287. Epub 2007 Jul 12 [MEDLINE]
  • Centers for Disease Control and Prevention, “Zika Virus-What Clinicians Need to Know?” Clinician Outreach and Communication Activity (COCA) Call 1/26/16 (Accessed 7/17) [LINK]
  • Centers for Disease Control and Prevention, “Geographic Distribution, Where Has Chikungunya Been Found? (Accessed 7/17) [LINK]