What are the signs and symptoms of chikungunya?

Signs and Symptoms of Chikungunya

Chikungunya presents as an acute febrile illness characterized by abrupt onset of high fever with severe polyarthralgia/polyarthritis, typically affecting the hands, wrists, ankles, and metatarsal-phalangeal joints of the feet, accompanied by constitutional symptoms and rash lasting 1-7 days. 1, 2, 3

Acute Phase Clinical Presentation

Primary Manifestations

• High fever develops after an incubation period of 5-7 days (range: 2-12 days) following mosquito bite 1, 4, 3
• Severe polyarthralgia and polyarthritis affecting multiple joints, particularly the small joints of hands, wrists, ankles, and feet—this joint pain is often debilitating and distinguishes chikungunya from other arboviral infections 5, 2, 4
• Maculopapular rash appearing during the acute febrile phase 2, 4, 3

Associated Symptoms

The acute illness includes multiple systemic manifestations that frequently accompany joint involvement:

• Myalgia and back pain—strongly associated with peripheral joint involvement (myalgia OR=4.65; back pain OR=16.77) 5
• Headache (OR=3.63 for association with joint involvement) 5, 4
• Retro-orbital/ocular pain (OR=8.88 for association with joint involvement) 5
• Gastrointestinal symptoms including nausea (OR=6.88), vomiting, diarrhea, and anorexia (OR=5.68) 5, 4

Key Clinical Features

• Joint pain severity: The arthralgia is characteristically severe and often poorly responsive to standard analgesics 6
• Joint distribution: Most commonly involves hands, wrists, ankles, and metatarsal-phalangeal joints bilaterally 4
• Duration of acute phase: Constitutional symptoms and rash typically last 1-7 days 2

Chronic Phase Manifestations

Post-Acute Complications

• Chronic chikungunya arthritis (CCA) develops in up to 50% of patients, defined as persistent joint pain and swelling lasting more than 12 weeks after acute infection 4
• Chronic rheumatism may persist for months to years, presenting as arthralgia or myalgia that mimics rheumatoid arthritis and significantly compromises quality of life 6, 4
• Chronic arthritis is characterized by swelling and acute pain that poorly responds to analgesics 6

Neurological Complications (Rare but Severe)

Central Nervous System Involvement

While uncommon, neurological presentations carry significant morbidity and mortality:

• Encephalitis and encephalopathy can occur, particularly in infants <1 year old and adults >60 years, with a 10% case fatality rate among patients with neurological presentation 1
• Other neurological manifestations include Guillain-Barré syndrome, acute disseminated encephalomyelitis, and febrile seizures 1
• Long-term neurological sequelae: Three years post-discharge, only 40% of adults with neurological involvement achieved full recovery; among infants, cerebral palsy and low developmental quotient were documented 1

Clinical Pearls and Diagnostic Considerations

Disease Course

• The disease is almost always self-limiting and rarely fatal in uncomplicated cases 2
• Peripheral joint involvement occurs in approximately 90.7% of acute chikungunya patients 5
• Symptoms typically appear 5-7 days post-infection, though the range extends from 2-12 days 1, 4

Differential Diagnosis Considerations

• Clinical presentation overlaps significantly with dengue fever, which also presents with fever, headache, retro-orbital pain, myalgia, arthralgia, and rash 1
• Cross-reactivity with other alphaviruses (particularly O'nyong-nyong virus) must be considered in serological testing 3

Diagnostic Timing

• PCR or viral culture is most effective during the first 5-7 days of symptoms 1, 7, 3
• IgM/IgG serology becomes positive from day 5-7 onwards and is appropriate for later-stage diagnosis 1, 7, 3