Chikungunya gudeilines 2023

1. Beyond Fever, Rash, Joint Pain
Dr Seebat Masrur
FCPS Part 2 Trainee(Cardiology)

2. Case Scenario
• A 32-year-old woman presents to the emergency
department with
• Sudden onset high-grade fever (103°F), headache, and
severe joint pain in wrists and ankles for 3 days.
• Mild maculopapular rash over trunk and limbs
• Recent travel history Dhaka 10 days prior

3. Is this dengue fever, or could it be something
else?
Initial Investigations:
• CBC: Mild lymphopenia, mild thrombocytopenia (platelets
~130,000/µL)
• NS1 antigen test for dengue: Negative
• IgM for dengue: Negative but IgG Negative
• Liver function tests: Mildly elevated ALT/AST
What else could present similarly if dengue is
excluded?

4. Chikungunya Virus
• A single-stranded RNA virus.
• Belongs to the Alphavirus genus within the Togaviridae
family.
• Initially isolated from human serum in Tanzania in 1952,
Chikungunya had, by 2004, spread across Africa, India, and
Southeast Asia, causing significant sporadic epidemics.
• There are three primary lineages: West African, Asian,
and ECSA.
• The name derives from the Kimakonde language, meaning
"to become contorted," a reference to the characteristic
joint pain posture.

5. Transmission
Transmits Chikungunya, dengue, Zika,
and yellow fever.
Humans serve as the main reservoir of
infection.
Active daytime painless biters with
black-white striped markings.
Lays eggs in tiny water-holding
containers.
Eggs can withstand dryness for 6–8
months.

6. • Blood-borne transmission is possible
• Rarely, vertical transmission during pregnancy
• No direct human-to-human transmission reported
• Outbreaks fuelled by urbanization, travel, and
vector expansion.

7. Global
History &
Spread
• First detected: Tanzania, 1952
• Reached Asia via Thailand (1958) → Endemic in
India, Sri Lanka, SE Asia
• Spread to Europe (Italy, 2007) – local transmission
• Landed in the Americas (2013) → Rapid spread
across South America
• Major outbreaks: Réunion (2005–06), India (2006),
Italy (2007, 2017)
• 🔄 From local threat to global concern due to travel
and vector adaptability

8. Bangladesh –
Epidemiology
• First cases in Rajshahi & Chapainawabganj (2008)
• Outbreaks: Dhaka (2011), Tangail (2012)
• 2017: >13,000 cases across 17 districts
• Likely underreported (limited diagnostics)
• Surges during monsoon and Eid travel
• 2024 resurgence in Dhaka = ⚠️New wave brewing
• ️
🌧️When it rains, it spreads

9. The Silent Surge
•⚠️Surge in Dhaka: 337 confirmed cases (Jan–
May 2025)
•🚨 Chattogram spike: 984 cases (Jun–Jul); Aedes
larvae found in 50% homes

10. Clinical
Presentation
• Incubation period: 3-7 days.
(1-12 days).
• Viremia lasts 5-7 days
(diagnostic window)
• Majority of infected
individuals become
symptomatic.

11. Clinical features of Chikungunya fever
Common Infrequent Rare in adults but seen
in
children
Fever
Arthritis/ Arthralgia
Backache
Headache
Rash
Stomatitis
Oral ulcers
Exfoliative dermatitis
Photosensitive
hyperpigmentation
Photophobia
Retro-orbital pain
Vomiting
Diarrhoea
Mental confusion
Signs of meningeal
irritation

12. Phases
Three primary clinical
presentations of the
disease:
Acute Phase-0–10 days
Subacute-11–90 days
Chronic->90 days (3
months)

13. Clinical Presentation
Acute Phase
• Sudden high-grade fever (>39°C)
• Symmetric polyarthralgia/arthritis – wrists, hands, ankles, knees
• Maculopapular rash in ~50% (appears a few days after fever)
• Myalgia, headache, conjunctivitis, eye pain, photophobia
• GI symptoms: nausea, vomiting, diarrhea (more in children)
• Rare: Neurological signs – encephalitis, Guillain-Barré syndrome

14. Subacute
Phase
•Persistent joint pain &
stiffness, esp. in previously
affected joints
•Morning stiffness, reduced
range of motion
•Fatigue, myalgia, emotional
changes (low mood, irritability)
•Inflammatory arthritis (RA-like)
•Skin & hair changes:
Hyperpigmentation, alopecia

15. Chronic Phase
(Virus-Free but
Still in Pain)
•Occurs in 30–40% of patients
•Joints: Chronic arthritis, synovitis,
osteoarthritis
•Tendons: Tendinitis, tenosynovitis
•Other: Neuropathic pain, stiffness,
postural hypotension
•Psychological: Mood disorders, loss of
physical fitness
•Women Are More Affected

16. Severe or Atypical presentations

17. High-risk Populations
• Elderly (>65yrs )
• Infants (Neuro-invasive risks)
• Pregnant Women (vertical transmission)
• People with comorbidities (HTN, DM, CAD, COPD,
CVD)
• Co-Infection: Dengue, HIV, Malaria

18. Rashes
•Typically appears 2–5 days after fever onset
•Often maculopapular, widespread on trunk,
limbs, face
•May be itchy, non-blanching, and sometimes
accompanied by hyperpigmentation
•More common in children and young adults
•May be transient or persist for several days

19. CHIKV Arthropathy
•Seen in up to 90% of symptomatic
patients; worse in the morning, improves
with movement
•Pain may follow a saddle-back pattern
(initial relief followed by relapse)
•Often affects previously injured joints
•Stooped posture common due to back
and limb pain
•Large joints (e.g., knees, shoulders)
may show swelling or effusion
•Locally known as "Langra Jor (ল্যাংড়া
জ্বর)", mimicking seronegative RA

20. RA CHIKV Arthritis
Onset Gradual Acute
Joint Involvement ALL Peripheral >
Central
Spine Cervical LS Spine
Erosions ++ -
Limb Oedema + ++

21. Diagnostic Approaches
• Goal: Early detection, rule out differentials, confirm ChikV
Clinical features: Fever ≥38.5°C, severe arthralgia/arthritis
• Epidemiological link: Travel to/residence in epidemic zone
within 15 days
• Laboratory confirmation: PCR / Serology
• Key differential exclusion: Dengue, malaria, COVID-19, other
alphaviruses

22. Investigations
•Select tests based on
timing for accuracy.
•Combine methods in
borderline or late
presentations.
•Always retest 5–7 days
after initial negative if
clinical suspicion remains
high
Time Since
Symptom
Onset
Recommende
d Test
Days 1–7 RT-PCR, Viral
Isolation
Days 5–14 IgM ELISA ±
RT-PCR
>Day 14 IgG serology
(paired
samples)

23. PCR
• Effective during the acute phase of
infection (within 8 days of symptom
onset)
• Samples can be taken from blood,
cerebrospinal fluid (CSF), or tissue
• After 8 days of symptom onset – viremia
usually resolves, reducing test sensitivity

24. Serology
•IgM: Becomes detectable around Day
5 and persists for several weeks
•IgG: Emerges approximately by Day
10 and remains for an extended period
Diagnostic criteria include:
•Presence of IgM along with symptoms
•OR a fourfold increase in IgG levels
between paired samples

25. Basic Laboratory Tests
TEST ABNORMALITY CLINICAL NOTES
CBC (Complete
Blood Count)
- Leukopenia (low
WBC count)
- Lymphopenia
- Thrombocytopenia
(mild or absent)
Mild drop in platelets
but rarely reaches
Dengue-level severity.
ESR/CRP Elevated Suggests systemic
inflammation; helpful in
persistent arthritis.
Liver Function
Test (LFT)
- Elevated ALT/AST Mild hepatic
involvement, more
common in adults.
Creatinine/Urea
Normal or mildy
raised
In rare severe or renal
cases, elevation may
occur.
Urine R/M/E Normal Unless nephritis

27.  Clinical Criteria
• Acute fever ≥ 38.5°C (101.3°F)
• Severe arthralgia or arthritis
 Epidemiological Criteria
• Travel or residence in
epidemic area
• Within 15 days before
symptom onset
 Laboratory Criteria
• RT-PCR or viral isolation
(BSL3)
• IgM detection + positive
neutralization
• IgG: 4-fold rise in paired sera
(14 days apart)
Case Definitions:
 Possible Case: Clinical +
exposure history, no
alternative diagnosis
 Probable Case: Clinical +
epidemiological match
 Confirmed Case: Positive
lab result regardless of
symptoms

28. General Principles of Treatment
• Chikungunya is a self-limiting viral illness.
• No targeted antiviral therapy is currently available.
• Most patients recover within 7–10 days, but joint pain
may persist.
• ✅ Key Focus: Symptomatic relief, prevention of
complications, and follow-up for chronic symptoms.

29. Acute Phase Management
•Supportive Care: Focus on rest and symptom relief.
•Fever Control: Paracetamol 500–1000 mg every 6 hrs. Avoid
NSAIDs early to rule out dengue.
•Pain Management:Paracetamol for mild cases; add Tramadol or
low-dose NSAID if pain is moderate–severe, only after ruling out
dengue.
•Hydration: Encourage ORS and adequate fluid intake.
•Monitor for Red Flags: Shock, bleeding, neurological
symptoms, hepatitis, or myocarditis.

30. Subacute Phase Management
• Common Issues: Persistent joint pain, stiffness, arthritis-like
symptoms
• NSAIDs (e.g., naproxen, diclofenac) initiated if dengue
excluded
• Short course of steroids (e.g., prednisolone 10–15 mg/day for
5–10 days) in:
– Severe polyarthritis
– Refractory synovitis
• Supportive Care: Physiotherapy, mental health monitoring, and
psychosocial support (especially in elderly or chronic cases)

31. Chronic Phase Management
•NSAIDs as needed with safety monitoring
•Low-dose corticosteroids for persistent inflammation
•DMARDs (e.g., methotrexate) in autoimmune arthritis (refer
specialist), Biologics-Etanercept, Infliximab
•Psychological support or antidepressants for mood
symptoms
•Rehabilitation: Graded physiotherapy and occupational
therapy

32. When to
Start
DMARDs
•Chronic arthritis ≥ 3 months
•Symptoms mimicking rheumatoid arthritis
•Inadequate response to NSAIDs and
corticosteroids
•Presence of synovitis, joint erosion, or
deformity
•Biologics are not first-line in post-viral arthritis
Reserved for
➤ severe, persistent, disabling
arthritis mimicking RA
Initiation requires
➤ rheumatologist’s
evaluation and decision

33. Prevention is Essential!
• No vaccine available for general population.
• Patients with viremia should avoid mosquito
bites
→ to prevent spread to Aedes mosquitoes.
• ✅ Prevention Measures:
• Use EPA-approved repellents (e.g., DEET,
permethrin-treated clothing)
• Wear long-sleeved clothes & trousers
• Eliminate mosquito breeding sites (stagnant
water)

34. Chikungunya Vaccine Update
(2024)
 VLA1553 (IXCHIQ™) – Valneva’s live-
attenuated, single-dose vaccine
• ✅ FDA-approved (Nov 2023) for adults ≥18
years
• Efficacy: 98.9% at Day 28, 96.3% at 6
months
• Placebo trial: 98.9% vs. 0% seroconversion
• ➕ Strong safety & durable immunity
 CHIKV-VLP – Emergent’s virus-like particle
vaccine
• In advanced Phase 3; may benefit
elderly/immunocompromised

35. Prognosis
Mortality is very
low (~0.1%), mainly
in elderly/comorbid
patients
Most recover within
1–2 weeks of acute
illness
30–40% may
develop persistent
joint pain or
arthritis-like
symptoms
Risk of chronic
arthritis ↑ in older
adults, women, and
those with rheumatic
disease
Rare
neurological/cardia
c complications
may occur
With proper care,
long-term outcome
is favorable, but
recovery can take
months to years

36. Reinfection with CHIKV
•Usually occurs only once due to strong
immune memory
•Infection triggers lifelong immunity via
neutralizing antibodies
•Reinfection is extremely rare, but may
occur with:
•Different viral strain
•Immunocompromised state
•Incomplete immunity
•➤ No large-scale reinfection outbreaks
have been reported

37. Take-Home Message
•Chikungunya is a mosquito-borne viral illness.
•Presents with sudden fever, rash, headache, and severe
joint pain.
•Chronic joint pain may persist for months or years.
•Always rule out dengue before initiating treatment.
•It is a self-limiting disease; supportive care is essential.
•Prevention through mosquito control is crucial.

38. Reference
•World Health Organization (WHO). Guidelines on Clinical Management
of Chikungunya Virus Infection, 2023–2024. Available at:
https://www.who.int
•Directorate General of Health Services (DGHS), Bangladesh. National
Guideline for Clinical Management of Chikungunya Fever. Dhaka: Ministry
of Health and Family Welfare, Bangladesh; 2024.
•Sharif AR, Dey SK, Rahman MS, et al. Molecular characterization of
Chikungunya virus during the 2017 outbreak in Dhaka, Bangladesh. Int J
Infect Dis. 2019;87:36–37. doi:10.1016/j.ijid.2019.08.100
•Harrison’s Principles of Internal Medicine (21st ed.)
Chapter: Arboviruses
•Oxford Handbook of Tropical Medicine (5th ed.)
•Centers for Disease Control and Prevention (CDC). Chikungunya Virus:
Clinical & Laboratory Evaluation. Yellow Book 2024. Available at:
https://www.cdc.gov/chikungunya

39. THANK YOU

41. Feature Chikungunya Zika
Fever (>38.5°C) +++ +
Arthralgia +++ (severe, disabling) + (mild to moderate)
Arthritis + -
Rash ++ (maculopapular) +++ (maculopapular)
Headache ++ +
Myalgia + +
Conjunctivitis - ++ (non-purulent)
Neurological symptoms Rare Possible (e.g., GBS)
Hemorrhage +/- -
Thrombocytopenia + Rare
Lymphopenia +++ +
Vertical transmission Rare Reported
Microcephaly risk No Yes (congenital)

42. Sub-Acute Arthritic Phase (2 Weeks–3 Months)
• Focus: Control inflammation, prevent chronicity
• PCM ± weak opioids for pain control
• Prednisolone 10–15 mg/day, taper over 8–12 weeks
• Gabapentin for persistent neuropathic symptoms
• Use VAS scale for pain monitoring
• Avoid NSAIDs while on steroids; no DMARDs yet

43. Chronic Phase (>3 Months)
• Focus: Prevent joint damage, long-term care
• Refer to Rheumatology for evaluation
• Use DMARDs: MTX, HCQ, Leflunomide
• ± low-dose steroids if symptoms persist
• Add physiotherapy, occupational therapy, joint
support
• Combination DMARDs preferred if severe arthritis

44. Viral Lineage
•There are three primary lineages: West African, Asian, and
ECSA.
•The Indian Ocean Lineage (IOL) is a highly virulent sub-
lineage within ECSA.
•It first appeared during the Réunion outbreak (2005–06).
•The Bangladesh outbreaks (2017, 2024) have been
associated with ECSA-IOL.
•It is effectively transmitted by Aedes albopictus
mosquitoes.
•Infection leads to severe joint pain and extended
arthralgia.

45. Newborns & Infants
• Clinical Presentation (3–7 days after birth):
• Fever, rash, poor feeding, lethargy, irritability.
• Limb edema, cyanosis, hyperalgesia.
• Neurological signs: seizures, encephalopathy, hypotonia.
• Rare: Myocarditis, hepatitis, coagulopathy.
• Prognosis:
• Most recover, but long-term neurodevelopmental delay
reported in severe neonatal cases.
• Close pediatric follow-up essential.

46. Chikungunya in Pregnancy
•Maternal Risk:
•Chikungunya is usually not more severe in pregnant women.
•Most cases are self-limiting, similar to non-pregnant adults.
•Vertical Transmission:
•Risk is highest when maternal infection occurs near delivery.
•Transmission is mainly intrapartum; rarely transplacental.
• No evidence of teratogenicity or fetal malformations.
Neonatal Outcomes:
• Infected neonates may develop encephalopathy, seizures, or
multi-organ involvement.
• Symptoms typically start 3–7 days after birth.

47. Feature Dengue Chikungunya
Onset
Usually 3–6 days after fever
onset
Appears 2–5 days after fever
onset
Type
Maculopapular or
petechial; may include
purpura
Maculopapular, morbilliform
(measles-like), or
scarlatiniform
Distribution Trunk, face, and
extremities
Mainly trunk and limbs, may
involve palms/soles
Itching Often absent or mild Frequently intensely itchy
Associated Signs "White islands in a sea of
red" (classic sign)
Rash may desquamate (peel
off) during recovery
Duration 2–3 days, self-limiting 3–7 days, sometimes
recurring