History

Fact Explanation
Mosquito bite Chikungunya virus is a mosquito-borne, single stranded RNA virus which belongs to the genus Alphavirus of the Togaviridae family [1,2,3] The virus is transmitted by Aedes aegypti and Aedes albopictus mosquitoes. Rarely in some areas, transmission by Culex, Mansonia, and Anopheles species has also been identified. [3]
Resident in Sub-Saharan Africa, South and East Asia or Indian Ocean region Chikungunya virus disease is epidemic in Sub- Saharan Africa, South and East Asia initially and then became epidemic in countries in Indian ocean region. [4,5]
Travel history Chikungunya virus disease must be considered in travelers who present with fever and arthritis after traveling to endemic areas or areas affected by an ongoing epidemic. [3]
High fever with rigors After biting of an infected mosquito on a human being, the virus replicates in the skin and then transmitted to the blood stream causing viraemia that causes high grade fever with or without rigors which is the most common symptom of the disease. [6,7] Fever occurs 2-4 days after infection and generally lasts for 3-7 days.[3,6] During the acute phase of the infection viral load in the blood stream can be increased up to billions of viral particles per ml of blood, inducing other pro-inflammatory cytokines and chemokines. [3]
Polyarthralgia According to some studies arthralgia is the most common post-chikungunya virus rheumatic disease. [1,2,7] In 90%of patients, mainly the peripheral joints such as wrists, ankles, and phalanges are affected. [3] This polyarthralgia is due to acute joint inflammation caused by the entry of the virus in to joints via blood stream.[7] According to some studies the virus can damage collagen and affects connective tissue metabolism in cartilage and joints. [14] This may persist for weeks, months, or even years. Chronic joint pain is mostly seen in such smaller joints as the wrists and ankles and is experienced by 30-40% of patient infected by the virus. [6] Persistent infection of synovial macrophages and chronic inflammation caused by activation of innate and adaptive immune responses may be the cause for this chronic arthralgia. [3,8]
Rash According to some studies macualar, macularpapular or peticheal rash can be seen in 75% of infected patients and 25% of them has complained of generalized pruritis. [1,2,3,9] It starts with the onset of the fever. [10] These xanthems can be due to viral infection of the skin and fibroblasts as seen in other viral exanthematous fevers. [6,9] Some studies suggest that paticheal rash may be due to thrombocytopenia. [9,10]
Myalgia Chikungunya virus replicates in human muscle satellite cells result in inflammation. but it does not replicate in differentiated myotubes. [6]
Headache The virus also identified in the epithelial and endothelial cell layers of brain and it targets the central nervous system at the acute stage of the disease. [6] Rare complications of the disease such as meningo-encephalitis can also cause headache. [11] According to some studies choroid plexi may also be targets of Chikungunya virus that cause infection of the central nervous system. [12] According to some studies about 47% of patients have complained about retro-orbital pain. [15]
Photophobia Chikungunya virus can replicate in the epithelial cells in the meninges that can cause photophobia. [6] Other than that rare complications such as meningo-enchephalitis can also cause photophobia.
Skin desquamation over the face, palms and soles This is due to subsiding inflammation in these areas. [9]
Nausea Chikungunya virus disaese generally starts with a flue like symptoms. One of rare complications of the disease, hepatitis can also cause nausea.[ 1,2,12] According to some studies about 43% of patients have experienced nausea. [14]
Vomoting Chikungunya virus disaese generally starts with a flue like symptoms. One of rare complications of the disease, hepatitis can also cause vomiting.[ 1,2,12] According to some studies about 44% of patients have experienced vomiting. [14]
Blurring of vision Chikungunya virus infection causes Iridocyclitis and retinitis. Those are the most common ocular manifestations of the disease and minority shows ocular lesions such as episcleritis. But these lesions get completely resolve with time and vision is preserved. [12,13]
Chest pain One of rare complications of chikungunya virus disease is myocarditis. [12]
A neonate Although this is a mosquito borne disease, some cases were reported due to maternal–fetal transmission.[3]
Yellowish discoloration of sclera Hepatitis can be a rare complication of the disease. [1,2,12,16]
Vertigo One of rare complication of chikungunya virus disease is post chikungunya reversible demyelinating encephalitis [17]
Ataxia One of rare complication of chikungunya virus disease is post chikungunya reversible demyelinating encephalitis [17]
Dysarthria One of rare complication of chikungunya virus disease is post chikungunya reversible demyelinating encephalitis [17]
References
  1. WANGCHUK SONAM, CHINNAWIROTPISAN PIYAWAN, DORJI TSHERING, TOBGAY TASHI, DORJI TANDIN, YOON IN-KYU, FERNANDEZ STEFAN. Chikungunya Fever Outbreak, Bhutan, 2012. Emerg. Infect. Dis. [online] 2013 October, 19(10):1681-1684 [viewed 03 September 2014] Available from: doi:10.3201/eid1910.130453
  2. VAN BORTEL W, DORLEANS F, ROSINE J, BLATEAU A, ROUSSET D, MATHEUS S, LEPARC-GOFFART I, FLUSIN O, PRAT C, CESAIRE R, NAJIOULLAH F, ARDILLON V, BALLEYDIER E, CARVALHO L, LEMAîTRE A, NOEL H, SERVAS V, SIX C, ZURBARAN M, LEON L, GUINARD A, VAN DEN KERKHOF J, HENRY M, FANOY E, BRAKS M, REIMERINK J, SWAAN C, GEORGES R, BROOKS L, FREEDMAN J, SUDRE B, ZELLER H. Chikungunya outbreak in the Caribbean region, December 2013 to March 2014, and the significance for Europe. Euro Surveill [online] 2014 Apr 3 [viewed 03 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/24721539
  3. TAUBITZ W., CRAMER J. P., KAPAUN A., PFEFFER M., DROSTEN C., DOBLER G., BURCHARD G. D., LOSCHER T.. Chikungunya Fever in Travelers: Clinical Presentation and Course. Clinical Infectious Diseases [online] 2007 July, 45(1):e1-e4 [viewed 03 September 2014] Available from: doi:10.1086/518701
  4. WALDOCK JOANNA, CHANDRA NASTASSYA L., LELIEVELD JOS, PROESTOS YIANNIS, MICHAEL EDWIN, CHRISTOPHIDES GEORGE, PARHAM PAUL E.. The role of environmental variables on biology and chikungunya epidemiology . Pathogens and Global Health [online] 2013 July, 107(5):224-241 [viewed 09 September 2014] Available from: doi:10.1179/2047773213Y.0000000100
  5. KHAN K, BOGOCH I, BROWNSTEIN JS, MINIOTA J, NICOLUCCI A, HU W, NSOESIE EO, CETRON M, CREATORE MI, GERMAN M, WILDER-SMITH A. Assessing the Origin of and Potential for International Spread of Chikungunya Virus from the Caribbean PLoS Curr [online] :ecurrents.outbreaks.2134a0a7bf37fd8d388181539fea2da5 [viewed 09 September 2014] Available from: doi:10.1371/currents.outbreaks.2134a0a7bf37fd8d388181539fea2da5
  6. SCHWARTZ OLIVIER, ALBERT MATTHEW L.. Biology and pathogenesis of chikungunya virus. Nat Rev Micro [online] 2010 July, 8(7):491-500 [viewed 03 September 2014] Available from: doi:10.1038/nrmicro2368
  7. YASEEN HAFIZ, SIMON FABRICE, DEPARIS XAVIER, MARIMOUTOU CATHERINE. Identification of initial severity determinants to predict arthritis after chikungunya infection in a cohort of French gendarmes. Array [online] 2014 December [viewed 03 September 2014] Available from: doi:10.1186/1471-2474-15-249
  8. HAWMAN D. W., STOERMER K. A., MONTGOMERY S. A., PAL P., OKO L., DIAMOND M. S., MORRISON T. E.. Chronic Joint Disease Caused by Persistent Chikungunya Virus Infection Is Controlled by the Adaptive Immune Response. Journal of Virology [online] December, 87(24):13878-13888 [viewed 03 September 2014] Available from: doi:10.1128/JVI.02666-13
  9. BHAT RAMESHM, RAI YASHASWI, RAMESH AMITHA, NANDAKISHORE B, SUKUMAR D, MARTIS JACINTHA, KAMATH GANESHH. Mucocutaneous manifestations of chikungunya fever: A study from an epidemic in coastal Karnataka. Indian J Dermatol [online] 2011 December [viewed 03 September 2014] Available from: doi:10.4103/0019-5154.82483
  10. PRASHANT SOMA, KUMAR AS, MOHAMMED BASHEERUDDIN DD, CHOWDHARY TN, MADHU B. Cutaneous manifestations in patients suspected of chikungunya disease. Indian J Dermatol [online] 2009 December [viewed 03 September 2014] Available from: doi:10.4103/0019-5154.53186
  11. KASHYAP RAJPAL S, MOREY SHWETA H, CHANDAK NITIN H, PUROHIT HEMANT J, TAORI GIRDHAR M, DAGINAWALA HATIM F. Detection of viral antigen, IgM and IgG antibodies in cerebrospinal fluid of Chikungunya patients with neurological complications. Array [online] 2010 December [viewed 03 September 2014] Available from: doi:10.1186/1743-8454-7-12
  12. CAGLIOTI C, LALLE E, CASTILLETTI C, CARLETTI F, CAPOBIANCHI MR, BORDI L. Chikungunya virus infection: an overview. New Microbiol [online] 2013 Jul, 36(3):211-27 [viewed 03 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/23912863
  13. BABU KALPANA, ADIGA MADHURA, GOVEKAR SUNIL R, KUMAR BV RAVI, MURTHY KRISHNA R. Associations of Fuchs heterochromic iridocyclitis in a South Indian patient population. Array [online] 2013 December [viewed 03 September 2014] Available from: doi:10.1186/1869-5760-3-14
  14. RAMACHANDRAN V, MALAISAMY M, PONNAIAH M, KALIAPERUAML K, VADIVOO S, GUPTE MD. Impact of Chikungunya on Health Related Quality of Life Chennai, South India PLoS One [online] , 7(12):e51519 [viewed 04 September 2014] Available from: doi:10.1371/journal.pone.0051519
  15. SISSOKO DAOUDA, EZZEDINE KHALED, MOENDANDZé AMRAT, GIRY CLAUDE, RENAULT PHILIPPE, MALVY DENIS. Field evaluation of clinical features during chikungunya outbreak in Mayotte, 2005-2006. [online] 2010 February [viewed 09 September 2014] Available from: doi:10.1111/j.1365-3156.2010.02485.x
  16. LIANG T. JAKE. Hepatitis B: The virus and disease. Hepatology [online] December, 49(S5):S13-S21 [viewed 09 September 2014] Available from: doi:10.1002/hep.22881
  17. PARASHAR D, CHERIAN S. Antiviral Perspectives for Chikungunya Virus Biomed Res Int [online] 2014:631642 [viewed 10 September 2014] Available from: doi:10.1155/2014/631642

Examination

Fact Explanation
Macular papular rash over the trunk and extremities This occurs with the onset of fever in majority of patients due to viral replication in skin. The rash generally subsides within 3-4 days without any complications. [1,2] Minority of patients have macular-papular rash over face, palms, and soles. [2]
Paticheal rash which does not bleach. Thrombocytopenia due to viraemia results in patecheak rash. [1]
Multiple, painful ulcers over the scrotum in males and labia majora in females This is the second most common cutaneous manifestation of Chikungunya infected patients.These ulcers appear 3-4 days after onset of fever and subside within 1-2 weeks.This may be due to viral triggered vasculitis. [1,2] These may be also complicated by superficial bacterial infections that causes pain. [2]
Hyperpigmented macules over sunexposed areas This can be attributed to the effect of solar UV rays [1,2]
Joint swelling The chikungunya virus enters in to the joints via blood stream causing inflammation. [3]
Erythema of joints The chikungunya virus enters in to the joints via blood stream causing inflammation. [3]
Reduced visual acuity Chikungunya virus infection causes Iridocyclitis and retinitis. Those are the most common ocular manifestations of the disease and minority shows ocular lesions such as episcleritis. [4]
Yellowish discoloration of sclera This is due acute hepatitis which is one of rare complications of chikungunya virus disease. [4]
References
  1. BHAT RAMESHM, RAI YASHASWI, RAMESH AMITHA, NANDAKISHORE B, SUKUMAR D, MARTIS JACINTHA, KAMATH GANESHH. Mucocutaneous manifestations of chikungunya fever: A study from an epidemic in coastal Karnataka. Indian J Dermatol [online] 2011 December [viewed 03 September 2014] Available from: doi:10.4103/0019-5154.82483
  2. PRASHANT SOMA, KUMAR AS, MOHAMMED BASHEERUDDIN DD, CHOWDHARY TN, MADHU B. Cutaneous manifestations in patients suspected of chikungunya disease. Indian J Dermatol [online] 2009 December [viewed 03 September 2014] Available from: doi:10.4103/0019-5154.53186
  3. SCHWARTZ OLIVIER, ALBERT MATTHEW L.. Biology and pathogenesis of chikungunya virus. Nat Rev Micro [online] 2010 July, 8(7):491-500 [viewed 03 September 2014] Available from: doi:10.1038/nrmicro2368
  4. CAGLIOTI C, LALLE E, CASTILLETTI C, CARLETTI F, CAPOBIANCHI MR, BORDI L. Chikungunya virus infection: an overview. New Microbiol [online] 2013 Jul, 36(3):211-27 [viewed 03 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/23912863

Differential Diagnoses

Fact Explanation
Dengue fever Both chikungunya and dengue disease show similar clinical symptoms. [1] Dengue fever also manifest as fever, headache, , arthralgia, , nausea, rash, itching of the skin. [2] Note: Both diseases are mosquito born. Dengue fever may lead to hemorrhagic manifestations and can lead to hemorrhagic shock. As this is life threatening the exact diagnosis is important. [2]
Sindbis virus disease Sindbis virus disease is a mosquito-borne alphaviral disease characterized by rash, fever and arthritis. Note: The joint involvement frequently leads to long-lasting arthralgia. [3]
Ross River virus disease The disease usually presents as peripheral polyarthralgia or arthritis. The patients sometimes present with fever and rash also. [4] Note: This is mosquito transmitted Alphavirus and is endemic in Australia and Papua New Guinea. [4]
O'nyong- nyong fever This also manifest as fever, maculopapular rash, pruritis, myalgia and arthralgias. [5] Note: This is a closely related alphavirus to chikungunya. [8]
Rheumatic fever This disease also manifest as fever joint involvement with arthritis and arthralgia, and rash. But the sequale of the disease is different. Rheumatic fever is complicated by carditis which is a rare complication of chikungunya virus disease. [6,7] Note: Other manifestations of Rheumatic disease is choria. Disease usually follows Streptococcal pharyngitis. [6]
Measles Manifest as maculopapular rash and fever. [9] Note: This is one of the most contagious viruses. Transmition is by respiratory droplets, or by direct or indirect contact with the nasal and throat secretions of infected persons. According to some studies 30% of reported cases of measles has had one or more complication. These complications include otitis media, pneumonia, diarrhoea, blindness and post-infectious encephalitis (1 per 1000 cases). [9]
Rubella Manifest as mild fever, maculopapular rash, hedache and arthralgia. Note: Postauricular or suboccipital adenopathy can also be seen. Thrombocytopenia and encephalitis are less common complications. Important: Though it is rare enchephalitis can be fatal. [9]
References
  1. OMARJEE R, PRAT C, FLUSIN O, BOUCAU S, TENEBRAY B, MERLE O, HUC-ANAIS P, CASSADOU S, LEPARC-GOFFART I. Importance of case definition to monitor ongoing outbreak of chikungunya virus on a background of actively circulating dengue virus, St Martin, December 2013 to January 2014. Euro Surveill [online] 2014 Apr 3 [viewed 04 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/24721537
  2. BRAGA JULIANA CRISTINA DUARTE, SILVA LEANDRO CéSAR DA, TIBúRCIO JACQUELINE DOMINGUES, SILVA MIRNA DE ABREU E, PEREIRA LAILAH HORáCIO SALES, DUTRA KARINA ROCHA, FERREIRA JAQUELINE MARIA SIQUEIRA, LOPES DéBORA DE OLIVEIRA, DOS SANTOS LUCIANA LARA. Clinical, Molecular, and Epidemiological Analysis of Dengue Cases during a Major Outbreak in the Midwest Region of Minas Gerais, Brazil. Journal of Tropical Medicine [online] 2014 December, 2014:1-6 [viewed 04 September 2014] Available from: doi:10.1155/2014/276912
  3. AHLM C., ELIASSON M., VAPALAHTI O., EVANDER M.. Seroprevalence of Sindbis virus and associated risk factors in northern Sweden. Epidemiol. Infect. [online] December, 142(07):1559-1565 [viewed 04 September 2014] Available from: doi:10.1017/S0950268813002239
  4. HARLEY D, SLEIGH A, RITCHIE S. Ross River Virus Transmission, Infection, and Disease: a Cross-Disciplinary Review Clin Microbiol Rev [online] 2001 Oct, 14(4):909-932 [viewed 04 September 2014] Available from: doi:10.1128/CMR.14.4.909-932.2001
  5. POSEY DL, O'ROURKE T, ROEHRIG JT, LANCIOTTI RS, WEINBERG M, MALONEY S. O'Nyong-nyong fever in West Africa. Am J Trop Med Hyg [online] 2005 Jul, 73(1):32 [viewed 04 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/16014827
  6. LAWRENCE JG, CARAPETIS JR, GRIFFITHS K, EDWARDS K, CONDON JR. Acute rheumatic fever and rheumatic heart disease: incidence and progression in the Northern Territory of Australia, 1997 to 2010. Circulation [online] 2013 Jul 30, 128(5):492-501 [viewed 04 September 2014] Available from: doi:10.1161/CIRCULATIONAHA.113.001477
  7. CAGLIOTI C, LALLE E, CASTILLETTI C, CARLETTI F, CAPOBIANCHI MR, BORDI L. Chikungunya virus infection: an overview. New Microbiol [online] 2013 Jul, 36(3):211-27 [viewed 03 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/23912863
  8. POWERS AM, BRAULT AC, TESH RB, WEAVER SC. Re-emergence of Chikungunya and O'nyong-nyong viruses: evidence for distinct geographical lineages and distant evolutionary relationships. J Gen Virol [online] 2000 Feb, 81(Pt 2):471-9 [viewed 04 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/10644846
  9. GENEVA: WORLD HEALTH ORGANIZATION; 2012 DEC. Surveillance Guidelines for Measles, Rubella and Congenital Rubella Syndrome in the WHO European Region. [Web][viewed 04 September 2014] Available from: http://www.ncbi.nlm.nih.gov/books/NBK143264/

Investigations - for Diagnosis

Fact Explanation
Complete Blood Count According to some studies Lymphopenia is a frequent presentation. Thrombocytopenia and neutropenia has reported less frequently. [1] Some studies suggest that type I IFNs induce cell death in lymphocytes can be happened. [2,3]In some studies lower lymphocytosis was associated with a shorter time duration between onset of symptoms and inclusion. [1]
Erythrocyte Sedimentation Rate This can be high due to inflammatory process of the body. [4]
C Reactive Protein According to some studies more than 80% patient has shown increased CRP. [1]
Enzime Linked Immuno-Sorbent Assay (ELISA)- This serological method can detect Chikungunya virus specific immune response. This is a rapid and sensitive method to detect Chikungunya specific antibodies. It can also distinguish between IgM and IgG. IgM can be detected 2-3 days after the onset of symptoms and last for several weeks, may be up to 3 months. [3] This is one of most reliable methods to confirm the diagnosis [5] Note: Serological investigation findings may be normal during the first week of the illness. [5]
Indirect Immunofluorescence assays (IFA) This serological method can detect Chikungunya virus specific immune response. This is a rapid and sensitive method to detect Chikungunya specific antibodies. It can also distinguish between IgM and IgG. IgM can be detected 2-3 days after the onset of symptoms and last for several weeks, may be up to 3 months. [3]
Hemoagglutination inhibition (HI) This is good method to identify recent infection. It cannot distinguish between IgG Ab from IgM Abs. This also helps to confirm the results obtained by other methods. [3]
Micro-neutralization (MNt) This is good method to identify recent infection. It cannot distinguish between IgG Ab from IgM Abs. This also helps to confirm the results obtained by other methods. [3]
Reverse Transcription-Polymerase Chain Reaction (RT-PCR) This molecular method helps to detect the viral RNA from blood samples rapidly before the antibody response is evident at the early stages of the disease. [3,5]
Virus isolation and culture This can be done from serum samples of suspected patients on insect or mammalian cell lines. Commonly monolayer of C6/36 cells or Vero E6 cells. This is good method in the early phase of the disease where there is high viral load and the immune response is not so evident. [3, 6]
Liver Function Test Because hepatiits is a rare complication of the disease it is important to assess the liver functions in these patients. According to some studies, abnormal liver function (ALT >45 IU/Land AST >35 IU/L) has found in 14% and 28% respectively. [1]
References
  1. THIBERVILLE SD, BOISSON V, GAUDART J, SIMON F, FLAHAULT A, DE LAMBALLERIE X. Chikungunya Fever: A Clinical and Virological Investigation of Outpatients on Reunion Island, South-West Indian Ocean PLoS Negl Trop Dis [online] , 7(1):e2004 [viewed 04 September 2014] Available from: doi:10.1371/journal.pntd.0002004
  2. SCHWARTZ OLIVIER, ALBERT MATTHEW L.. Biology and pathogenesis of chikungunya virus. Nat Rev Micro [online] 2010 July, 8(7):491-500 [viewed 03 September 2014] Available from: doi:10.1038/nrmicro2368
  3. CAGLIOTI C, LALLE E, CASTILLETTI C, CARLETTI F, CAPOBIANCHI MR, BORDI L. Chikungunya virus infection: an overview. New Microbiol [online] 2013 Jul, 36(3):211-27 [viewed 04 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/23912863
  4. HASSAN R, RAHMAN MM, MONIRUZZAMAN M, RAHIM A, BARUA S, BISWAS R, BISWAS P, MOWLA SG, CHOWDHURY MJ. Chikungunya - an emerging infection in Bangladesh: a case series J Med Case Rep [online] :67 [viewed 04 September 2014] Available from: doi:10.1186/1752-1947-8-67
  5. TAUBITZ W., CRAMER J. P., KAPAUN A., PFEFFER M., DROSTEN C., DOBLER G., BURCHARD G. D., LOSCHER T.. Chikungunya Fever in Travelers: Clinical Presentation and Course. Clinical Infectious Diseases [online] 2007 July, 45(1):e1-e4 [viewed 04 September 2014] Available from: doi:10.1086/518701
  6. SONI MANISHA, SINGH ANIL KUMAR, SHARMA SHASHI, AGARWAL ANKITA, GOPALAN NATARAJAN, RAO P. V. LAKSHMANA, PARIDA MANMOHAN, DASH PABAN KUMAR. Molecular and Virological Investigation of a Focal Chikungunya Outbreak in Northern India. The Scientific World Journal [online] 2013 December, 2013:1-6 [viewed 04 September 2014] Available from: doi:10.1155/2013/367382

Investigations - Followup

Fact Explanation
ELISA to detect serum IgM and IgG levels. According to some studies specific IgM can lasts for about 3 to 4 months from the onset of symptoms, and specific IgG lasts more than 6 months. [1]
Inflammatory markers C reactive protein (CRP) According to some studies the CRP levels were significantly high in patients with arthralgia at 36 months following the acute illness than patients without arthralgia. [2] So this can be used for the follow up of patients with chronic joint involvement. Other inflammatory markers such as factor VII, C3 complement component, Interleukien 1α, Interleukien 15 have also shown an increase in patients with chronic joint pain. [2]
References
  1. AOYAMA I, UNO K, YUMISASHI T, TAKASAKI T, LIM CK, KURANE I, KASE T, TAKAHASHI K. A case of chikungunya fever imported from India to Japan, follow-up of specific IgM and IgG antibodies over a 6-month period. Jpn J Infect Dis [online] 2010 Jan, 63(1):65-6 [viewed 04 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/20093767
  2. SCHILTE C, STAIKOVSKY F, COUDERC T, MADEC Y, CARPENTIER F, KASSAB S, ALBERT ML, LECUIT M, MICHAULT A. Chikungunya Virus-associated Long-term Arthralgia: A 36-month Prospective Longitudinal Study PLoS Negl Trop Dis [online] , 7(3):e2137 [viewed 09 September 2014] Available from: doi:10.1371/journal.pntd.0002137

Investigations - Screening/Staging

Fact Explanation
Enzime Linked Immuno-Sorbent Assay (ELISA) This serological method can detect Chikungunya virus specific immune response. This is a rapid and sensitive method to detect Chikungunya specific antibodies. It can also distinguish between IgM and IgG. IgM can be detected 2-3 days after the onset of symptoms and last for several weeks, may be up to 3 months. [1]
References
  1. CAGLIOTI C, LALLE E, CASTILLETTI C, CARLETTI F, CAPOBIANCHI MR, BORDI L. Chikungunya virus infection: an overview. New Microbiol [online] 2013 Jul, 36(3):211-27 [viewed 04 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/23912863

Management - General Measures

Fact Explanation
Fluid management Important to prevent getting dehydration [1]
Patient education People should be educated about the symptoms of the disease especially people in endemic areas, such as sub-Saharan Africa, South and East Asia. Not only them travelers should also be educated about the symptoms. Because following returning their own countries, these individuals could introduce the virus into areas where autochthonous transmission can happen. [2] Identification of symptoms and looking for medical advise are important not only for identify chikungunya virus disease but also to differentiate it with the Dengue virus disease. [3] Important rare complications of the disease, should be also explained, such as hepatitis, enchephalitis, Iridocyclitis, retinitis and myocarditis because these can lead to significant morbidity. [4,5,6] Patient should be educated about importance of taking adequate fluid. [1] Patients should be advised to use mosquito nets during the acute phase because the disease can spread via mosquitoes of the area. [7 ]Information about mosquito control methods is another important fact that should be conveyed to the community.
Control of transmission Patients in acute phase of the illness and healthy individuals in endemic areas should be encouraged to use mosquito nets and repellents to control transmission. It should be keep in mind that Aedes mosquitoes are active all day long. [7]
Vector control Breeding sites of Aedes mosquitoes such as man made containers ( tires and motor parts. Drums, barrels, water-pots ) must be removed and destroyed frequently and can be treated with insecticides. [1,8] Use of dichlorodiphenyltrichloroethane is effective against A. aegypti but not A. albopictus as mentioned in some studies. [1]
Prevention of epidemics By closely monitoring of reporting of fever cases will be helpful for identifying areas for providing initial control measures. The importance of fever reporting and proper case management should be emphasize to health Institutions, professional associations, private practitioners and Non Governmental Organizations. [9]
References
  1. CAGLIOTI C, LALLE E, CASTILLETTI C, CARLETTI F, CAPOBIANCHI MR, BORDI L. Chikungunya virus infection: an overview. New Microbiol [online] 2013 Jul, 36(3):211-27 [viewed 04 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/23912863
  2. KHAN K, BOGOCH I, BROWNSTEIN JS, MINIOTA J, NICOLUCCI A, HU W, NSOESIE EO, CETRON M, CREATORE MI, GERMAN M, WILDER-SMITH A. Assessing the Origin of and Potential for International Spread of Chikungunya Virus from the Caribbean PLoS Curr [online] :ecurrents.outbreaks.2134a0a7bf37fd8d388181539fea2da5 [viewed 09 September 2014] Available from: doi:10.1371/currents.outbreaks.2134a0a7bf37fd8d388181539fea2da5
  3. OMARJEE R, PRAT C, FLUSIN O, BOUCAU S, TENEBRAY B, MERLE O, HUC-ANAIS P, CASSADOU S, LEPARC-GOFFART I. Importance of case definition to monitor ongoing outbreak of chikungunya virus on a background of actively circulating dengue virus, St Martin, December 2013 to January 2014. Euro Surveill [online] 2014 Apr 3 [viewed 04 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/24721537
  4. KASHYAP RAJPAL S, MOREY SHWETA H, CHANDAK NITIN H, PUROHIT HEMANT J, TAORI GIRDHAR M, DAGINAWALA HATIM F. Detection of viral antigen, IgM and IgG antibodies in cerebrospinal fluid of Chikungunya patients with neurological complications. Array [online] 2010 December [viewed 03 September 2014] Available from: doi:10.1186/1743-8454-7-12
  5. CAGLIOTI C, LALLE E, CASTILLETTI C, CARLETTI F, CAPOBIANCHI MR, BORDI L. Chikungunya virus infection: an overview. New Microbiol [online] 2013 Jul, 36(3):211-27 [viewed 03 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/23912863
  6. BABU KALPANA, ADIGA MADHURA, GOVEKAR SUNIL R, KUMAR BV RAVI, MURTHY KRISHNA R. Associations of Fuchs heterochromic iridocyclitis in a South Indian patient population. Array [online] 2013 December [viewed 03 September 2014] Available from: doi:10.1186/1869-5760-3-14
  7. CHUNDAWAT BHAGWATI. Profile of The Chikungunya Infection: A Neglected Vector Borne Disease which is Prevalent In The Rajkot District. JCDR [online] 2013 December [viewed 09 September 2014] Available from: doi:10.7860/JCDR/2013/5307.3057
  8. RAO TR, TRPIS M, GILLETT JD, TEESDALE C, TONN RJ. Breeding places and seasonal incidence of Aedes aegypti, as assessed by the single-larva survey method Bull World Health Organ [online] 1973, 48(5):615-622 [viewed 09 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2482938
  9. NARESH KUMAR CV, SAI GOPAL DV. Reemergence of Chikungunya virus in Indian Subcontinent Indian J Virol [online] 2010 Jun, 21(1):8-17 [viewed 09 September 2014] Available from: doi:10.1007/s13337-010-0012-1

Management - Specific Treatments

Fact Explanation
Non steroidal anti-inflammatory drugs (NSAID) Anelgesics such as ibuprofen (400mg three times per day), naproxen (500mg twise daily), [1] acetaminophen ( 325–650 mg every 4 hours while symptoms persist, not to exceed 3900 mg in 24 hours for not more than 10 days) [2]can be used to relive myalgia and arthralgia by relive inflammation [3] How ever these should be used with caution as Dengue fever can be presented with same clinical features. And also there should be no evidence of bleeding. Paracitamol (1g 6hrly) can be also used to relive pain. [3] NSAIDs act by inhibiting prostaglandin and prostanoids biosynthesis by COX enzymes. [4] Adverse effects of NSAIDs include gastrointestinal side effects such as dyspepsia, heartburn and nausea, renal side effects such as renal papillary necrosis, acute interstitial nephritis, hyperkalemia and sodium and fluid retention, cardiovascular risk factors such as hypertension. [4]
Disease modifying drugs People with chronic joint involvement has successfully treated with methotrexate during the 2005-2006 La Réunion outbreak. [5] But this drug has serious side effects such as myelosuppression, hepatic, renal and pulmonary disorders.[6] Treating with Hydroxychloroquine or sulfasalazine for 6 month duration has also shown some efficacy in patient with arthralgia. [7] Above drugs have gastrointestinal side effects such as nausea, headache, and abdominal discomfort,temporary reversible rash, proteinuria, and also some serious side effects such as marrow suppression and drug induced hepatitis. [8]
Steroids Have been occasionally used but the efficacy is not so significant. [3] Some studies recomend that use of low dose systemic corticosteroids together with NSAIDs gives a synergistic effect. [5] Side effects of long term use of these drugs include bruising, muscle weakness, weight gain, skin changes, sleep disturbances, cataracts, and pathologic fractures and ect. [9]
Antiviral drugs Although there are no proven specific treatment options for this viral disease, following drugs have been used in studies with small groups of patients that have shown some positive results. 1) Ribavirin - (200 mg twice a day for seven days) [3]This anti viral agent used to be effective in patient with arthritis to relive joint and tissue swelling in some studies. They have also found a synergistic effect of ribavirin and interferon-α towards the inhibition of Chikungunya virus replication. [10] Also not very significant, photosensitive type drug eruption with has been reported. [11] Although ribavirin is the most commonly used antiviral drug, following drugs have been also shown some efficacy. 2) Coumarin 30 - This drug is useful for inhibiting the replication of Chikungunya virus. [8] 3) Harringtone - this is a cephalotoxine alkaloid, that inhibits the early stages of Chikungunya virus replication. [10]
Vaccination Although there are no licensed vaccines available at the moment, several types of vaccines are being investigated in humans and animals with various degrees of success. [3]
References
  1. ONG C.K.S., LIRK P., TAN C.H., SEYMOUR R.A.. An Evidence-Based Update on Nonsteroidal Anti-Inflammatory Drugs. Clinical Medicine & Research [online] 2007 March, 5(1):19-34 [viewed 11 September 2014] Available from: doi:10.3121/cmr.2007.698
  2. KRENZELOK EDWARD P., ROYAL MIKE A.. Confusion. Drugs R D [online] December, 12(2):45-48 [viewed 11 September 2014] Available from: doi:10.2165/11633010-000000000-00000
  3. CAGLIOTI C, LALLE E, CASTILLETTI C, CARLETTI F, CAPOBIANCHI MR, BORDI L. Chikungunya virus infection: an overview. New Microbiol [online] 2013 Jul, 36(3):211-27 [viewed 03 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/23912863
  4. HARIRFOROOSH S, ASGHAR W, JAMALI F. Adverse effects of nonsteroidal antiinflammatory drugs: an update of gastrointestinal, cardiovascular and renal complications. J Pharm Pharm Sci [online] 2013, 16(5):821-47 [viewed 10 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/24393558
  5. PARASHAR D, CHERIAN S. Antiviral Perspectives for Chikungunya Virus Biomed Res Int [online] 2014:631642 [viewed 10 September 2014] Available from: doi:10.1155/2014/631642
  6. AL-QUTEIMAT OM, AL-BADAINEH MA. Practical issues with high dose methotrexate therapy Saudi Pharm J [online] 2014 Sep, 22(4):385-387 [viewed 10 September 2014] Available from: doi:10.1016/j.jsps.2014.03.002
  7. HOARAU J. J., JAFFAR BANDJEE M. C., KREJBICH TROTOT P., DAS T., LI-PAT-YUEN G., DASSA B., DENIZOT M., GUICHARD E., RIBERA A., HENNI T., TALLET F., MOITON M. P., GAUZERE B. A., BRUNIQUET S., JAFFAR BANDJEE Z., MORBIDELLI P., MARTIGNY G., JOLIVET M., GAY F., GRANDADAM M., TOLOU H., VIEILLARD V., DEBRE P., AUTRAN B., GASQUE P.. Persistent Chronic Inflammation and Infection by Chikungunya Arthritogenic Alphavirus in Spite of a Robust Host Immune Response. The Journal of Immunology [online] December, 184(10):5914-5927 [viewed 10 September 2014] Available from: doi:10.4049/jimmunol.0900255
  8. PAULUS HE. An overview of benefit/risk of disease modifying treatment of rheumatoid arthritis as of today Ann Rheum Dis [online] 1982, 41(Suppl 1):26-29 [viewed 11 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1030289
  9. ERICSON-NEILSEN W, KAYE AD. Steroids: Pharmacology, Complications, and Practice Delivery Issues Ochsner J [online] 2014, 14(2):203-207 [viewed 11 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4052587
  10. BETTADAPURA J, HERRERO LJ, TAYLOR A, MAHALINGAM S. Approaches to the treatment of disease induced by chikungunya virus Indian J Med Res [online] 2013 Nov, 138(5):762-765 [viewed 04 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3928707
  11. SHINDO MASAHISA, TERAI ISAMU. Adverse Skin Reactions due to Ribavirin in Hepatitis C Combination Therapy with Pegylated Interferon-a2a. Case Rep Dermatol [online] 2013 December, 5(3):379-381 [viewed 11 September 2014] Available from: doi:10.1159/000357516