What is the management and treatment approach for pediatric patients with Chikungunya-associated neurologic deficits and encephalitis?

Management of Chikungunya-Associated Neurologic Deficits and Encephalitis in Pediatrics

Pediatric patients with Chikungunya-associated encephalitis should be managed using the same evidence-based approach as other viral encephalitides, with immediate supportive care, urgent neurological assessment within 24 hours, and comprehensive rehabilitation planning, as there is no specific antiviral therapy available for Chikungunya virus. 1, 2

Immediate Assessment and Stabilization

Patients with falling level of consciousness require urgent assessment by pediatric Intensive Care Unit staff for:

• Airway protection and ventilatory support 1, 2
• Management of raised intracranial pressure 1, 2
• Optimization of cerebral perfusion pressure 1, 2
• Correction of electrolyte imbalances 1, 2

All patients with suspected Chikungunya encephalitis should have access to pediatric neurological specialist opinion and be seen within 24 hours of referral. 1, 2 This is critical because children with Chikungunya can develop severe neurological complications including encephalitis, meningoencephalitis, seizures, and acute encephalopathy, with mortality rates documented in pediatric series. 3, 4, 5

Diagnostic Workup

Neuroimaging should be obtained urgently:

• MRI is the preferred modality and should be obtained within 48 hours, as it detects cerebral changes in approximately 90% of encephalitis cases versus only 25% for CT 2
• Brain MRI may show white matter lesions or discrete hippocampal high signal in approximately 60% of cases 6
• In the pediatric Chikungunya series from La Réunion, brain MRI was abnormal in 5 of 14 cases (36%), and patients with pathological brain MRI had more sequelae or fatal disease 4

Cerebrospinal fluid analysis is essential:

• CSF should be obtained unless contraindicated by significant brain shift/swelling or tight basal cisterns 1
• In pediatric Chikungunya encephalitis, CSF analyses are often unremarkable, though viral genome detection in CSF is inconstantly positive 4
• CSF PCR for Chikungunya virus should be sent, along with testing for other viral causes including HSV 1 & 2, VZV, and enteroviruses 1, 2

EEG should be obtained when:

• Distinguishing psychiatric versus organic causes in patients with mildly altered behavior 2
• Subtle motor or non-convulsive seizures are suspected 2
• EEG is abnormal in >80% of encephalitis cases but was nonspecific in the pediatric Chikungunya series 2, 4

Treatment Approach

Supportive Care (Primary Management)

There is no specific antiviral therapy for Chikungunya virus. 7 Management is entirely supportive, which differs from HSV encephalitis where aciclovir is strongly indicated. 1

Supportive measures include:

• Seizure management with appropriate anticonvulsants as needed 4, 5
• Fluid and electrolyte management 1
• Nutritional support 1
• Management of complications such as myocarditis or hemorrhagic manifestations 3, 5

Special Considerations for Severe Cases

Children with Chikungunya can develop:

• Extensive skin blisters requiring dermatologic care 3
• Cardiac complications including myocarditis and hemodynamic disorders requiring intensive monitoring 3, 5
• Hemorrhagic manifestations requiring hematologic support 3
• Acute disseminated encephalomyelitis (ADEM), which would warrant high-dose corticosteroids 1, 2

If ADEM is suspected based on clinical presentation and MRI findings, high-dose corticosteroids should be administered as first-line therapy, with alternatives including plasma exchange or intravenous immunoglobulin. 1, 2 However, corticosteroids are not routinely recommended for viral encephalitis without evidence of immune-mediated pathology. 1, 2

Transfer Criteria

Transfer to a specialist pediatric neuroscience unit should occur when:

• Diagnosis is not rapidly established 1
• Patient fails to improve with supportive therapy 1
• Access to specialized neuroimaging under general anesthesia is needed 1
• Transfer should occur as soon as possible and definitely within 24 hours of being requested 1

Prognostic Factors

Poor prognostic indicators in pediatric Chikungunya encephalitis include:

• Initial severe neurologic presentation 4
• Pathological brain MRI findings 4
• Development of coma or circulatory failure 3
• Massive hemorrhage 3

In the La Réunion pediatric series, 2 of 30 children with neurologic manifestations died, and 5 had neurologic sequelae at 6-month follow-up. 4 In the Honduras series, there were 2 childhood deaths from meningoencephalitis and myocarditis among 235 hospitalized children. 5

Rehabilitation and Long-Term Management

All children should have access to comprehensive rehabilitation assessment. 1, 2 This is particularly important for Chikungunya encephalitis, as survivors may present long-term neurologic or dermatologic sequelae. 3

A broad rehabilitation approach should include:

• Neuropsychology assessment 1
• Child and adolescent mental health teams 1
• Speech and language therapists 1
• Neuro-physiotherapists 1
• Occupational therapists 1
• Access to specialist brain injury rehabilitation services 1

Sequelae may not be immediately apparent at discharge. 1 Anxiety, depression, and behavioral problems such as intrusive obsessive behavior, challenging behavior, or hyperactivity/concentration difficulties often become evident subsequently. 1

Discharge Planning

At discharge, children should have:

• Either a definite or suspected diagnosis 1
• Arrangements for outpatient follow-up 1, 2
• Plans for ongoing therapy and/or rehabilitation formulated at a discharge meeting 1

Parents and older children should be informed about:

• The diagnosis and its consequences 1
• Support provided by voluntary sector partners 1
• How to access information and services 1

In one survey, one third of encephalitis patients were discharged without them or their families being informed of the diagnosis, and 33% were discharged without outpatient follow-up although 96% reported ongoing complications. 1

Common Pitfalls

Avoid these errors:

• Delaying neurological consultation beyond 24 hours 1, 2
• Discharging without rehabilitation assessment, as sequelae may emerge later 1
• Failing to obtain MRI when CT is normal, as MRI is far more sensitive 2
• Assuming benign course based on typical Chikungunya presentation—children are at higher risk for neurological complications than adults 4, 7, 5
• Not considering ADEM in the differential, which would change management to include immunosuppression 1, 2