Call Girl Coimbatore Prisha☎️ 8250192130 Independent Escort Service Coimbatore
Chikungunya
1.
2. In Swahili it means ‘to become contorted’ or
More specifically as ‘that which bends up’
Refers to the stooped posture of the patient
A viral infection transmitted to humans
By the bite of an infected mosquito
It has become endemic in south and central
India
First outbreak in 1952 on the Makonde Plateau
Border between Tanganyika and Mozambique
www.drsarma.in 2
3.
4. Genus – alpha virus.
Family – Togaviridae.
An enveloped positive-strand RNA virus.
Genetic analysis showed three distinct
lineages: the West African cluster, the East-
Central and South African cluster (ECSA),
and the Asian cluster.
To date, no difference in virulence between
the different strains of CHIKV has been
shown in humans.
6. Reservoir – Non-human primates in Africa
Vector – Aedes aegypti, Ae. albapticus
mosquito
Same vector as for Dengue and Yellow fevers
No known mode - other than mosquito bite
Incubation Period – 2 days to 12 days or 3-7
days
www.drsarma.in 6
7. Aedes aegypti and Aedes albaptycus
mosquito, flight range < 100 meters
Aggressive daytime biter – under lights – bites
ankles
Once infected – it has the virus until death (30
days)
Indoor, peridomestic, fresh water mosquito
Metallic, plastic, rubber, cement and earthen
containers - open, left or unused - get filled
with water
www.drsarma.in 7
11. Epidemic of CHIKV occurred in Malaysia – 1999
French island of Réunion in the Indian Ocean- 2005
Epidemic was recorded in Mauritius – 2005
Madagascar, Mayotte and Seychelles – 2005
Hong Kong and Malaysia early 2006
Present indian epidemic is the largest -from nov ’05
Maximum # of cases from Andhra Pradesh so far
12. Present epidemic has started in Nov 2005
Andhra Pradesh, Karnataka, Maharashtra,
Madhya Pradesh, Orissa, Gujarat, Tamilnadu,
Rajasthan, Kerala are under its onslaught
This is spreading far and wide at a rapid rate
Not much spread to the northern states like
Delhi, Haryana, Punjab as yet.
www.drsarma.in 12
13. Analysis of the recent Indian epidemic has
suggested that the increased severity of the
disease is due to a change in the genetic
sequence, altering the virus’ coat protein,
which potentially allows it to multiply more
easily in mosquito cells*.
www.drsarma.in 13
14. At the early stage of the disease, the organs
targeted for CHIKV replication were
lymphoid tissues, liver, CNS, joints, and
muscle.
The persistence of CHIKV could be found
later in the lymphoid organs, liver, joints, and
muscle, macrophages being the main
reservoir.
15. In humans, acute CHIKV infection is
characterized by a very early viremia at fever
onset that can increase up to 109 to 1012 RNA
copies/ml and lasts up to 12 days .
In vitro studies have shown that human
epithelial and endothelial cells, primary
fibroblasts, and monocyte-derived
macrophages are susceptible to CHIKV
infection, whereas activated B and T CD4+
lymphocytes, monocytes, and monocyte-
derived dendritic cells were refractory to CHIKV
infection .
16. Sudden onset of fever, chills
Headache, nausea, vomiting, abdominal
pain
Joint pain with or without swelling,
Low back pain and Maculopapular rash
Very similar to those of Dengue but
Unlike in Dengue, no hemorrhagic or shock
syndrome
www.drsarma.in 16
17. Incubation period is 2-12 d; usually 3-7 days
Viremia last for 5 days (infective period)
Silent CHIKV – inapparent infections in children
High grade fever (40°C or 104°F),
Flu-like symptoms, Severe headache and chills
Arthralgia or arthritis – lasting several weeks
Conjunctival suffusion and mild photophobia
Nausea, vomiting, abd. pain, severe weakness
www.drsarma.in 17
18. The small joints of the lower and upper limbs
Migratory poly arthralgia – not much effusions
Larger joints may also be affected (knee, ankle)
Pain worse in the morning – less by evening
Joints may be swollen & painful to the touch
Some patients have incapacitating joint pains
Arthritis may last for weeks or months.
www.drsarma.in 18
23. A petechial or maculo papular rash usually
involving the limbs may occur.
Hemorrhage is rare
Nasal blotchy erythema, freckle-like
pigmentation over centro-facial area,
Flagellate pigmentation on face and
extremities
Lichenoid eruption and hyper pigmentation in
exposed areas
www.drsarma.in 23
24. Multiple aphthous-like ulcers over
› scrotum, crural areas and axilla
Unilateral or bilateral lympoedema of the
limbs
Lymphadenopathy not common
Multiple ecchymotic spots in children
Vesiculo-bullous lesions in infants and
Sub-ungual hemorrhages
Severe menigo-encephalitis – rare; may be
fatal
www.drsarma.in 24
25. Fever typically lasts for 2 - 3 days and comes down
Fever may reoccur after 3 days – ‘saddle back’ fever
Some rare cases - fever lasts up to a couple of weeks
Patients do have prolonged fatigue for several weeks
High fever & crippling joint pain marked this epidemic
Joint pain, intense headache, insomnia and an extreme
degree of prostration may last for 5 to 7 days
Life long immunity, once one suffers this infection
www.drsarma.in 25
26. Pregnant women
Elderly people
Newborns
Women in general
Diabetics
Immuno-compromised patients
Patients with severe chronic illnesses
www.drsarma.in 26
27. Chikungunya is a self-limiting illness
Causes of prolonged morbidity are
› Severe dehydration
› Electrolyte imbalance and
› Loss of glycemic control
Recovery is the rule
In about 3 to 5%
› Incidence of prolonged arthritis
www.drsarma.in 27
28. A few deaths have been reported - Examples
It was thought to be due mainly to
› Inappropriate use of antibiotics and NSAIDs
› Virus can cause thrombocytopenia
› These drugs can cause gastric erosions - thus
› Leading to fatal upper GI bleed
› Use of steroids for the joint pains & inflammation
› This is dangerous and completely unwarranted
www.drsarma.in 28
29. Mother to fetus transmission can occur
Reported between 3 to 4.5 months of gestation
Maternal IgG develops in 2 weeks after CHIKV
This passes through placenta – confers protection
Intra-partum risk is 48% if mother has viremia
Neonatal infections are very mild; fully recover
No miscarriages or congenital malformations
www.drsarma.in 29
30. Within the first 3 months, the life of patient infected
with CHIKV impaired by –
Early exacerbation,
Inflammatory relapses, often triggered after
exposure to cold.
Long-lasting rheumatism, and
A significant loss in the quality of life.
31. Ocular changes :
Develop a few weeks after disease onset
Anterior uveitis, retinitis, episcleritis, and
optic neuritis,sometimes leading to
blindness.
Deterioration is more frequent in patients over
40 years of age and/or with underlying diseases
32. Chikungunya infection, chronic stage with swollen and stiff hands
in a 55-year-old man who was infected 5 years earlier.
33. Chikungunya infection, chronic stage with
inflammatory osteoarthritis of the second
and third metatarsophalangeal joints on the
left foot of a 43-year-old man who was
infected 5 years earlier
34. Dengue fever, DHF, DSS
Other non specific viral fevers
Any other acute fever like malaria, UTI etc.
www.drsarma.in 34
35. CLINICAL
SIGNS
CHIKUNGUNYA DENGUE
Fever Common Common
Rash Day 1 – Day 4 Day 5 – Day 7
Retroorbital pain Rare Common
Arthralgia Constant Rare
Arthritis Common, edematous Absent
Myalgia Common Common
Tenosynovitis Common Absent
Hypotension Possible Common, Day 5 – Day
7
Minor bleeding Rare Common, Day 5 – Day
7
Outcome Possible Raynaud
syndrome,Month2-Month3
Possible Tenosynovitis,Month2-
Month3.
Common persistence of arthralgia
for months to years.
Possible fatigue for
weeks
36. 1. Four fold or more rise of HI Antibody
2. IgM capture ELISA using MAbs
3. Indirect Immuno Flourescence Test (I IFT)
› On infected cells from tissues
4. Virus Isolation – Infant Swiss Albino mice
› Vero BHK-21 cell lines are used
5. Nucleic acid amplification by PCR & RT PCR
www.drsarma.in 36
37. IgM capture ELISA – Good serological test
Not commercially available
NIV – Pune, NICD – Delhi only
Positive after 5-10 days & lasts up to 6
months
HI Antibody appears on day 3 or 4
RT –PCR confirmatory – before the 5th day
www.drsarma.in 37
38. There is no specific treatment for CHIKV
No vaccine or preventive pill is available
The illness is usually self-limiting
It will resolve with time over a week to 10
days
No relapses occur – no second attacks
Convalescence may take longer
Symptomatic treatment only
www.drsarma.in 38
39. Rest to the patient and mild movements of joints
Cold compresses to inflamed joints
Liberal fluid intake or IV fluids
Analgesics and NSAIDS
› Paraetamol ± Ibuprofen or aceclofenac or
diclofenac
› Naproxen sodium (Naprasyn, Xenobid)
› Aspirin should be avoided
Hydroxy chloroquine sulphate (HCQS) 200 mg/od
Chloroquine phosphate 250 mg/od
www.drsarma.in 39
40. No indication for antibiotics
Never use costly, large spectrum drugs
No indication for long acting steroids
No indication for short term steroids also
in the acute phase of illness
Rarely, if the joint swelling persists – we
may consider use of steroids in short burst.
www.drsarma.in 40
41. Using NSAIDs during early or late stages of
pregnancy is not associated with congenital
anomalies, prematurity, or low birth weight, but
There is a significant link between NSAID use
and miscarriage in the first trimester.
In third trimester may cause premature delivery
Recommend stopping NSAIDS 6 to 8 weeks
before delivery to prevent premature closure of
fetal ductus arteriosus.
www.drsarma.in 41
42. Use insect repellent such as DEET on exposed skin.
Wear long sleeves & pants, treat clothes with permethrin
Have secure screens on windows and doors
Get rid of mosquito breeding sites by
› Emptying standing water from flower pots, buckets etc.,
› Change the water in pet dishes in bird baths weekly
› Drill holes in tire swings so water drains out
› Keep children's wading pools empty
www.drsarma.in 42
44. Cover all tanks, cisterns, barrels, containers
Remove old tyres, tins, buckets and bottles
Clogged gutters and drains need to be cleared
Change water in dip trays, plant pots twice
week
Tanks need to be covered and cleaned - 2
weeks
Weeds and tall grass to be cut short – ↓ hiding
Temephos 1 ppm for large water tanks
www.drsarma.in 44
47. CDC. Chikungunya Fever Diagnosed Among International Travelers — United States,
2005‒2006. MMWR 2006; 55(38): 1040‒1042.
CDC. Update: Chikungunya Fever Diagnosed Among International Travelers —
United States, 2006. MMWR 2007; 56(12): 276-277.
Gibney KB, et al. Chikungunya fever in the United States: a fifteen year review of
cases. Clin Infect Dis 2011; 52(5): e121‒126.
Lanciotti RS, et al. Chikungunya virus in US travelers returning from India, 2006.
Emerg Infect Dis 2007; 13(5): 764–767.
Powers AM, Logue CH. Changing patterns of chikungunya virus: re-emergence of a
zoonotic arbovirus. J Gen Virol 2007; 88(Pt 9): 2363–2377.
Renault P, et al. A major epidemic of chikungunya virus infection on Reunion Island,
France, 2005–2006. Am J Trop Med Hyg 2007; 77(4): 727–731.
Rezza G, et al. Infection with chikungunya virus in Italy: an outbreak in a temperate
region. Lancet 2007; 370(9602): 1840–1846.
Staples JE, et al. Chikungunya fever: an epidemiological review of a re-emerging
infectious disease. Clin Infect Dis 2009; 49(6): 942–948.
World Health Organization. Outbreak and spread of chikungunya. Wkly Epidemiol
Rec; 82(47): 409–415.