What is the treatment for Chikungunya fever?

Treatment of Chikungunya Fever

Chikungunya fever treatment is primarily supportive with acetaminophen for pain and fever relief, adequate hydration, and strict avoidance of NSAIDs during the acute phase (first 7-10 days) due to bleeding risk, particularly when dengue co-infection cannot be excluded. 1

Acute Phase Management (First 7-10 Days)

Pain and Fever Control

• Acetaminophen at standard doses is the recommended analgesic and antipyretic for acute chikungunya fever 2, 1
• Avoid aspirin and NSAIDs during the acute phase due to potential bleeding risk, especially since dengue co-infection cannot always be ruled out immediately (both diseases share the same Aedes mosquito vector) 1
• This NSAID restriction is critical because dengue causes platelet dysfunction and increases bleeding risk 2

Hydration Management

• Provide adequate oral hydration, preferably with oral fluids unless the patient cannot tolerate oral intake 1
• Target fluid intake exceeding 2500ml daily for adequate hydration 2
• Use oral rehydration solutions for moderate dehydration 2

Diagnostic Confirmation

• PCR testing is most effective during the first 1-4 days of symptoms for direct viral detection 1
• IgM antibody testing should be used from day 5 of symptoms onward 1
• The incubation period is typically 2-3 days (range: 1-12 days) 1

Chronic Arthritis Management (Beyond Acute Phase)

Disease-Modifying Therapy

• For patients developing persistent disabling arthritis that does not improve after months, disease-modifying anti-rheumatic drugs (DMARDs) such as methotrexate (20 mg/week) and/or leflunomide (20 mg/day) with short-term dexamethasone (0-4 mg/day for 4 weeks) have shown significant benefit 3
• DMARDs reduced pain more effectively than hydroxychloroquine (mean difference -14.80,95% CI -19.12 to -10.48) 4
• DMARDs also reduced disability (mean difference -0.74,95% CI -0.92 to -0.56) and disease activity (mean difference -1.35,95% CI -1.70 to -1.00) compared to hydroxychloroquine 4

Alternative Chronic Treatment Options

• Chloroquine showed better chronic pain relief than placebo (relative risk 2.67,95% CI 1.23 to 5.77), though evidence quality is very low 4
• However, the systematic review emphasizes that evidence from available trials is insufficient to draw firm conclusions about efficacy or safety of any specific intervention 4

High-Risk Populations Requiring Close Monitoring

Elderly Patients (>60 Years)

• Higher risk for severe manifestations and neurological complications 5, 1
• Monitor closely for encephalitis, encephalopathy, and Guillain-Barré syndrome 5, 1
• Case fatality rate of approximately 10% has been observed among patients with neurological manifestations 1

Pregnant Women

• Monitor closely as vertical transmission can occur, particularly near term 1
• Maternal-fetal transmission can lead to severe complications in neonates 1
• Acetaminophen remains the safest analgesic option for pregnant women 2

Infants and Neonates

• Require close monitoring as they are at higher risk for severe disease 1
• Severe encephalitis following probable mother-to-child perinatal transmission has been reported 5
• Three years after discharge from neurological complications, only 1 in 13 infants had apparent full recovery, with some developing cerebral palsy 5

Children

• Acetaminophen dosing must be carefully calculated based on weight 2

Monitoring for Complications

Neurological Complications

• Monitor for rare but serious neurological complications including encephalitis, encephalopathy, acute disseminated encephalomyelitis, myelitis, and Guillain-Barré syndrome 5, 1
• These complications are severe conditions with poor neurocognitive outcomes 5
• CNS involvement is more severe in adults than infants, though both age groups are affected 5

Joint Symptoms

• Joint symptoms and signs usually last for months and occasionally for 1 year or longer 6
• Severe joint pain and stiffness can incapacitate patients from a few days to several months after infection 7

Common Pitfalls to Avoid

• Do not use NSAIDs during the acute phase when dengue co-infection cannot be excluded 1
• Misdiagnosis as dengue fever due to similar initial presentation and shared Aedes mosquito vector 1
• Failure to consider chikungunya in the differential diagnosis of travelers returning from endemic areas 1
• Prescribing interventions based on insufficient evidence—physicians should be cautious in prescribing and policy-makers should be cautious in recommending any intervention given the very low quality of available evidence 4

Key Clinical Pearls

• Classic presentation includes fever, headache, myalgia, and severe polyarthralgia/arthritis 1
• Deaths from chikungunya infection are rare 6
• No specific antiviral treatment exists; treatment consists of supportive care 6
• Currently there are no approved vaccines for chikungunya virus 7