Chikungunya: Clinical Presentation and Management
Acute Phase Symptoms
Chikungunya presents with a characteristic triad of polyarthralgia (97% of cases), fever (96%), and skin rash (57%), typically appearing 2-3 days after mosquito bite exposure. 1, 2
Core Clinical Features
- Fever: High-grade fever lasting an average of 4 days (range 3-14 days), often abrupt in onset 1, 2
- Joint Pain (Polyarthralgia): Severe, often debilitating joint pain affecting multiple sites simultaneously 1, 2
- Skin Rash: Maculopapular rash appearing in approximately 57% of cases 2
Associated Symptoms
- Headache: Present in most cases, lasting an average of 3.8 days 2
- Retro-orbital pain: Frequently reported alongside headache 1
- Myalgia: Muscle pain throughout the body 1, 4
- Back pain: Particularly prominent arthralgia 1
- Gastrointestinal symptoms: Nausea, vomiting, and diarrhea may occur 3
Diagnostic Approach
For acute diagnosis within the first 5-7 days, PCR testing on serum is the gold standard; after day 5-7, IgM antibody testing becomes appropriate. 1, 5
- Early phase (days 1-5): Viral PCR or nucleic acid amplification tests on serum 1, 5
- Later phase (day 6 onwards): IgM capture ELISA for serological confirmation 1, 5
- Laboratory findings during acute phase: Lymphocytosis (65%) and granulocytopenia (43%) are common 2
Management Strategy
Treatment is entirely supportive, as there is no specific antiviral therapy for chikungunya; acetaminophen at standard doses is the exclusive recommended analgesic. 5, 4
Symptomatic Treatment
- Pain and fever control: Acetaminophen (paracetamol) at standard doses only 5
- Avoid NSAIDs and aspirin: These medications should be avoided until dengue is definitively ruled out due to bleeding risk 5
- Hydration: Maintain adequate oral fluid intake with oral rehydration solutions 5
- Rest: Encourage rest during acute febrile phase 4
Mosquito Bite Prevention During Illness
- Critical public health measure: Patients must avoid mosquito bites during the acute viremic phase to prevent local transmission 6, 4
- Aedes mosquitoes (primary vectors) are day-biting species, requiring daytime protection 1
Chronic Phase and Long-Term Complications
Persistent joint pain beyond 12 weeks (chronic chikungunya arthritis) occurs in 21-52% of patients, with higher initial viral loads and delayed neutralizing antibody responses predicting worse outcomes. 2, 7, 3
Risk Factors for Chronicity
- Age >41 years: Significantly associated with persistent joint pain (OR: 1.588) 2
- High initial viral load: Patients with higher viremia during acute phase have poorer prognosis with more restricted joint movement 7
- Delayed IgG seroconversion: Early neutralizing IgG response correlates with better outcomes and less chronic arthralgia 7
Chronic Arthritis Characteristics
- Duration: Joint pain persists at 3 months in 52% and at 6 months in 21% of cases 2
- Pattern: Chronic polyarthritis resembling rheumatoid arthritis in distribution and severity 3
- Management: Advanced pharmacological interventions may be required as pain often does not respond well to simple analgesics 2
Severe Neurological Complications (Rare)
While uncommon, chikungunya can cause severe neurological manifestations including encephalitis, particularly in infants <1 year and adults >60 years, with a 10% case-fatality rate among those with neurological involvement. 1
- Encephalitis/encephalopathy: Most severe in very young infants and elderly adults 1
- Other presentations: Guillain-Barré syndrome, acute disseminated encephalomyelitis, febrile seizures 1
- Long-term sequelae: Poor neurocognitive outcomes reported, including cerebral palsy in infants and incomplete recovery in adults 1