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

Chikungunya Virus is an Arbovirus (Arthropod-Borne Virus) (see Arboviruses)

• Family Togaviridae
• Genus Alphavirus

Routes of Transmission

• Bite from Infected Mosquito (see Mosquito Bite)
  • Aedes Aegypti
    • Note: Aedes Mosquitoes Can Also Transmit Dengue Virus and Zika Virus (see Dengue Virus and 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)

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 and 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

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 and Zika Virus) (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)
  • Epidemiology: may occur in some cases

Dermatologic Manifestations

• Macular or Maculopapular Rash (see Macules and 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)
  • Epidemiology: occur in some cases (mostly in children)
• Hyperpigmentation (see 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)
  • Epidemiology: may occur

Hematologic Manifestations

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

Neurologic Manifestations

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

Ophthalmologic Manifestations

• Conjunctivititis (see 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)

Otolaryngologic Manifestations

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

Pulmonary Manifestations

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

Renal Manifestations

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

Rheumatologic Manifestations

• Bilateral Symmetric Polyarthralgias (see 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)
• Chondritis of External Ear
  • Epidemiology: may occur in some cases

Other Manifestations

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

Persistent/Relapsed Chikungunya Fever

Rheumatologic Manifestations

• Arthritis/Arthralgias (see Arthritis and Arthralgias): involving the fingers and toes
• Carpal Tunnel Syndrome (see Carpal Tunnel Syndrome): due to hypertrophic tenosynovitis
• Cryoglobulinemia (see Cryoglobulinemia)
• Raynaud’s Phenomenon (see 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)
• Poor Feeding
• Rash
• Peripheral Edema (see Peripheral Edema)
• Thrombocytopenia (see 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 International Normalized Ratio/Prothrombin Time (see xxxx)

Protection from Mosquito Bites

• Clothing
• Insect Repellant
• Mosquito Netting
• Staying Indoors

Mosquito Control

• Eliminate Standing Water Sources

Acute Chikungunya Fever

Supportive Care

• Hydration
• Analgesics: as required for pain
  • Acetaminophen (Tylenol) (see Acetaminophen)
  • Nonsteroidal Anti-Inflammatory Drugs (NSAID’s) (see Nonsteroidal Anti-Inflammatory Drug)
• 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
  • Acetaminophen (Tylenol) (see Acetaminophen)
  • Nonsteroidal Anti-Inflammatory Drugs (NSAID’s) (see Nonsteroidal Anti-Inflammatory Drug)
• Medications to Treat Neuropathic Pain
  • Gabapentin (Neurontin) (see Gabapentin)
  • Pregabalin (Lyrica) (see Pregabalin)
• Physical Therapy
• Systemic Glucocorticoids (see 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
  • Acetaminophen (Tylenol) (see Acetaminophen)
  • Nonsteroidal Anti-Inflammatory Drugs (NSAID’s) (see Nonsteroidal Anti-Inflammatory Drug)
• Methotrexate (see Methotrexate): may be required in some cases with persistent symptoms >3 mos

Chronic Chikungunya Fever

• Methotrexate (see Methotrexate): may be used (similarly as that used in rheumatoid arthritis)
• Sulfasalazine (see Sulfasalazine)
• Anti-Tumor Necrosis Factor-α Agents (she Anti-Tumor Necrosis Factor-α Therapy)