What is the typical arthritis pattern in chikungunya infection and what are the recommended management strategies?

Arthritis Pattern in Chikungunya

Chikungunya causes symmetric polyarthritis predominantly affecting small joints of the hands, wrists, ankles, and feet in a pattern that closely mimics seronegative rheumatoid arthritis, with up to 80% of patients developing chronic musculoskeletal manifestations lasting beyond 3 months. 1, 2

Acute Phase Arthritis Pattern

The acute arthritis develops after a 5-7 day incubation period (range: 2-12 days) and presents with the following characteristics: 1

• Symmetric polyarthralgia/polyarthritis affecting multiple joints simultaneously 1, 2
• Most commonly involved joints (in order of frequency): 2, 3
  • Fingers and small joints of hands
  • Wrists
  • Ankles
  • Knees
  • Metatarsophalangeal joints of feet
• Associated features include high fever, myalgias, and maculopapular rash lasting 1-7 days 1
• The pattern is nearly identical to seronegative RA, with 8 of 10 patients in one cohort meeting ACR/EULAR 2010 criteria for RA 4

Chronic Arthritis Pattern (>3 Months)

Up to 80% of patients develop persistent musculoskeletal manifestations beyond 3 months, representing the most common long-term complication. 2

The chronic phase demonstrates: 2, 5

• Persistent or relapsing-remitting polyarthritis in a symmetric distribution 2, 3
• Small joint predominance continues, though proximal joints and axial involvement can emerge in chronic stages 2
• Pseudorheumatoid pattern with inflammatory joint pain, morning stiffness, and functional impairment 5
• Additional manifestations include tenosynovitis and enthesopathy 5
• Laboratory findings show mild elevation of acute phase reactants with negative autoimmune markers 5

Management Strategies

Acute Phase Treatment

The Centers for Disease Control and Prevention recommends: 2

• First-line: Acetaminophen and NSAIDs for symptomatic relief 2
• Alternative approach: Low-dose corticosteroids for 1-2 months may provide superior relief of acute rheumatic symptoms, though this represents off-guideline use based on observational data 2

Chronic Arthritis Treatment (>3 Months)

For patients with persistent arthritis beyond 3 months, initiate disease-modifying antirheumatic drugs (DMARDs) with close rheumatologic monitoring. 2, 6

The treatment algorithm based on available evidence: 2, 5, 6

1. Hydroxychloroquine in combination with low-dose corticosteroids as initial therapy 2, 5
2. Methotrexate (20 mg/week) alone or in combination with leflunomide (20 mg/day) for refractory cases 2, 6
3. Sulfasalazine alone or combined with methotrexate as alternative DMARD strategy 2
4. Short-course dexamethasone (0-4 mg/day for 4 weeks) can be added for rapid symptom control 6

In a Brazilian cohort of 133 patients, 4 weeks of methotrexate/leflunomide with dexamethasone reduced DAS28-ESR from 6.0 to 2.7 (P<0.001) with sustained improvement at 5 months follow-up. 6

Critical Clinical Pitfalls

Do not dismiss chronic chikungunya arthritis as self-limiting—early DMARD initiation is crucial for patients with symptoms persisting beyond 3 months to prevent long-term disability. 2

• The disease can induce true rheumatoid arthritis or seronegative spondyloarthropathies in genetically susceptible individuals, not just post-viral arthralgia 2
• Chikungunya can cause cryoglobulinemia, adding diagnostic complexity 2
• In non-endemic areas, consider chikungunya in the differential diagnosis of new-onset symmetric polyarthritis with recent travel history 5, 4
• Neurological complications occur in high-risk populations (infants <1 year, adults >60 years) with 10% mortality in this subset 1