Chikungunya

Chikungunya, which means “that which bends up” in Swahili was first described in
Tanzania in 1952. It is caused by a virus and is transmitted by the Aedes Aegypti mosquito –
recognisable by its distinct white patches. The Chikungunya virus is transmitted by vector
propagation. It should be noted that human transition is not possible and a person who is
infected with the virus is not contagious.
The symptoms of the disease usually appear after 4 to 7 days after having been bitten
by the Aedes Aegypti. It's only then that the frightening things happen. High fever that can go
up to 39oC is achieved and some skin rashes appear on the skin. Afterwards, the infected
person suffers from muscular and joints pain. In acute cases, the patient finds himself in the
incapability to walk or even talk. Although death follows in extreme cases only, some 150
people succumbed to the disease in Reunion Island according to the World Health
Organisation (WHO).
Chikungunya is a re-emerging, mosquito-borne viral infection causing fever,
rash and acute or sudden severe joint pains of several joints.Chikungunya (Chick’-en-
GUN-yah) in Swahili an African language meaning “that which contorts or bends up”
refers to the contorted (stooped) posture of patients who are afflicted with severe joint
pains (arthralgia) the most common feature of the disease.
Chikungunya virus is a single-stranded RNA Alphavirus, from the family
Togaviridae. Other Alphaviruses also causing fever, rash and arthralgia, include
O’nyong-nyong, Mayaro, Barmah Forest, Ross River and Sindbis viruses.
Chikungunya virus is most closely related to O’nyong-nyong, but remains genetically
distinct.

The disease was first described by Marion Robinson and W.H.R. Lumsden, following
an outbreak along the border between Tanzania(erstwhile Tanganyika) and
Mozambique, in1952. Since 1953, the virus has caused outbreaks in Africa and South
Eastern Asia, including India, Sri Lanka, Myanmar, Thailand, Indonesia, the
Philippines and Malaysia, which are well documented. There is historical evidence
that Chikungunya virus originated in Africa and subsequently spread to Asia.
Phylogenetic studies support this theory, with Chikungunya virus strains falling into
three distinct genotypes based on origin from West Africa, Central/East Africa or
Asia.
Chikungunya is transmitted by the bite of the infected Aedes mosquito from an
infected person to a healthy person. The disease does not get transmitted directly from
human to human (i.e. it is not a contagious disease). In a pregnant woman with
Chikungunya there is risk of transmitting the disease to her foetus.
The fever starts usually about 2 to 3 days after the entry of virus into the human body.
There will be severe chills and shaking of the body at the onset of fever. At the same
time the joint pain and swelling starts. The patient will not be able to move within
minutes of onset of illness. The joints of hands mainly the metacarpo phalangeal and
proximal inter phalange joints become warm swollen and very painful. Wrist and
elbow are also affected to a lesser extent. The joints of ankle, feet and to a lesser
extend hip are all affected.
Itchy reddish raised rash is typically seen [70%] when the fever subsides, which in
most of my patients was by 3 days. Many patients and Physicians confuse it with drug
rash due to allergy to the medicines the patient took for fever and joint pain.
Rash is typically seen on the cheeks, nose and outer part of ears. The ear lobe is
typically painful to touch. The rash is also seen over the trunk and limbs with severe
itching which lasts for only 2 days. There will be painful swelling of ankle and shin
with dark red discoloration. Painful oral ulcers are also seen during this time. Last
year I had few patients with enlarged cervical lymph nodes, which disappeared in few
days.

Although rare, the infection can result in meningo-encephalitis, especially in

newborns and those with pre-existing medical conditions. Pregnant women can pass
the infection to their foetus. Severe cases of Chikungunya can occur in the elderly, in
very young ones (newborns) and in those who are immuno-compromised.

Chikungunya outbreaks typically result in several hundreds or thousands of cases but

deaths are rarely encountered.
Differential diagnosis of Chikungunya includes Dengue and Dengue Haemorrhagic
Fever,
O’nyong-nyong virus infection and Sindbis virus infection.
It has been reported that attack rates in susceptible populations may be as high as 40-
85 per cent and the ratio of symptomatic to asymptomatic patients is about 1.2:1.

Children are less likely to experience joint pain, but may have other features such as
febrile fits, vomiting, abdominal pain and constipation.

The discoloration of the nose usually lasts for months. It is the seal of Chikugunya, as
a person who had Chikungunya in the recent past can be identified, seeing that seal.
Some patients may remain feverish for some more days. The joint pain becomes less
in few days. In about 60 percent of the patients the illness including the joint pains
last only about a week. They become completely all right with only a little bit of
tiredness remaining.
But in about 40% of patients joint pain increases or persists. The chronic joint pain of
Chikungunya resembles that of Rheumatoid arthritis. The joints commonly involved
are the wrists and the knees. The ankle and smaller joints of feet and hands are also
involved. Stiffness of these joints in the morning lasting more than 30 minutes is
typical. The patient feels better as he/she continues to move the joints.
The joint stiffness and pain lasts for about 3 months in about 30% of patients. But in
an unfortunate 10%, it may last indefinitely.

Lab Diagnosis of Chikungunya fever

Virus isolation and PCR techniques are costly and is available in very few centres.
Serological diagnosis is possible only after a week of onset by detecting antibodies.
As the treatment is mostly symptom specific diagnosis will not alter patient
management much. So the typical triad of fever, acute onset joint pains and rash along
with a low white cell count in blood sample is sufficient enough to diagnose
Chikungunya fever

Treatment of Chikungunya fever

Paracetamol 10 to 15mg per kg body weight given 3 to 4 times a day reduces the
fever.It is needed only in the first 2 to 3 days of illness.

Non Steroidal anti inflammatory agents have to be given liberally to reduce the pain
and swelling. This may have to be continued for few weeks in some patients with
persistent joint pain. Renal and Gastric safety have to ensure while taking such
medicines.
Short course of steroids like Prednisolone also helps in resistant cases.
Other analgesics like Tramadol are also useful.
Disease modifying anti rheumatic agents like Chloroquine have been found useful in
some studies. Chloroquine is not of much help as it is a slow acting drug taking
almost 3 months to be fully effective.

Most of the patients who turned to alternative systems of medicine for relief came
back to me saying there is no relief to pain. Many had to take NSAIDs along with
their Ayurvedic and Homeopathic medicines which proved that other systems have
nothing much to offer.

In short Chikungunya fever is easy to diagnose but not that easy to treat, but to those
who suffer it is pure hell.