When should I suspect chikungunya in a child?

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Elsevier ClinicalKey Clinical Overview

Diagnosis Chikungunya virus has an incubation period of 1 to 12 days after transmission by mosquito bite Patient may present with the following signs and symptoms: Fever (92% of patients) Fever varies from low-grade to high-grade, lasting 24 to 48 hours May rise abruptly and reach 39 °C to 40 °C Fever does not exhibit diurnal variation May be accompanied by shaking chills Patient may report that fever improved with use of antipyretics Arthralgia (87%) Patients may present with arthralgia without fever Joint pain tends to be worse in the morning and is typically relieved by mild exercise and exacerbated by aggressive movements Joint symptoms are typically symmetrical and often occur in hands and feet Can be severe and debilitating Joint pain may remit for 2 to 3 days and then reappear Backache (67%) Headache (62%) Rash is common (50%), usually maculopapular Neurologic symptoms (33%): Meningoencephalitis appears to be the most common manifestation, especially in children Headache, with or without stiff neck Altered level of consciousness; may be coupled with seizures Vomiting and diarrhea may occur, particularly in infants Febrile seizures may occur without other evidence of central nervous system involvement Patients may present with ocular symptoms (eg, ocular or retro-orbital pain, photophobia, blurred or tunnel vision) associated with ocular manifestations (ie, uveitis, neuroretinitis, neuritis) Parents of infants with the disease may report poor feeding, crying, and suspicion of pain

Diagnosis Fever is common; with severe disease and dehydration, heart rate may be elevated (or low, if shock is present), pulse weak, and blood pressure low Patients may have characteristic stooped posture due to pain Hallmark of the disease, from which it derives its name, meaning that which bends up Migratory polyarthritis with effusions may be observed in approximately 70% of cases Often symmetrical Typically, the most severely affected joints are the following: Ankles Wrists Small joints of hand Larger joints may also be involved, including: Knees Shoulders Spine Enthesitis is a common extra-articular feature Transient maculopapular rash (up to 50% of patients) Maculopapular eruption persists for more than 2 days in approximately 10% of cases Other skin manifestations may include: Intertriginous aphthouslike ulcers Vesiculobullous eruptions Angiomatous lesions Purpuras Photosensitivity with hyperpigmentation in sun-exposed areas Exfoliative dermatitis Stomatitis (25% of patients) Oral ulcers (15% of patients) Other signs may include: Ocular manifestations (eg, conjunctival injection) may be associated with abnormalities on funduscopic or slit-lamp examination Optic nerve edema Dendritic lesions Hemorrhagic signs are rare (1%-7% of patients) and minor (eg, bleeding nose or gums) May include a positive tourniquet test result and petechiae Infants infected intrapartum are often asymptomatic at birth, but most develop clinical illness within 7 days after delivery Common signs in neonates include fever, rash, and peripheral edema Severely ill infants may develop seizures or respiratory distress (meconium aspiration, heart failure) Infants may resist passive motion or change in position, resuming original position of comfort (so-called elastic baby sign)

Diagnosis Confirmed diagnosis of chikungunya infection can be made only by laboratory testing, through at least 1 of the following: Viral culture results may be positive very early (within 3 days or fewer of illness onset), but specimens present a biosafety hazard and testing is not recommended in most cases Reverse transcription polymerase chain reaction is the test of choice for patients presenting early in disease course (7 days or fewer) IgM antibody may be detectable during acute illness (4 days or more), but cross-reaction with other viruses limits specificity unless confirmed by disease-specific neutralizing antibody test IgG values in samples collected at least 3 weeks apart (acute and convalescent titers) Chikungunya testing is performed at the CDC, several state health departments, and some commercial laboratories During an epidemic: Characteristic triad of fever, rash, and arthralgia should trigger suspicion of chikungunya All patients need not be subjected to confirmatory laboratory tests An epidemiologic link may be sufficient for diagnosis Possible cases of chikungunya are those that meet the clinical criteria for diagnosis: Acute onset of fever higher than 38.5 °C Severe arthralgia/arthritis not explained by other medical conditions Probable cases of chikungunya are those that meet the clinical criteria as well as the following epidemiologic criteria: Patient residing in or having visited endemic areas is aware of exposure within 15 days before symptom onset Blood tests that are nonspecific for chikungunya but are often done during evaluation of a febrile illness include: CBC with differential Serum chemistry panel including electrolyte levels and kidney and liver function tests Joint Doppler ultrasonography may be used to visualize synovitis Testing for dengue and Zika virus infection is recommended for patients suspected of having chikungunya

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Elsevier ClinicalKey Clinical Overview

Diagnosis Differential diagnosis is broad Many conditions may be difficult to distinguish from the febrile phase of dengue, especially in travelers Malaria Fever and travel history to malaria endemic area Incubation period for malaria may be as long as 4 weeks, whereas dengue usually presents within 10 days Fevers can be recurrent with malaria; nausea and vomiting are often present Differentiated by presence of malarial parasites on blood smear or positive rapid malaria test result Chikungunya virus infection Spread by the same mosquito vectors as dengue virus infection Fever and travel history to (or residence in) areas with reported chikungunya virus transmission, including subtropical and tropical areas of the Americas and the Caribbean, suggest possibility of infection or coinfection with chikungunya virus and dengue virus Fever, rash, and myalgias are present in both dengue and chikungunya, but debilitating symmetrical bilateral arthralgias and arthritis are prominent features of chikungunya Lymphopenia occurs with chikungunya virus infection, whereas neutropenia is more likely in dengue virus infection Test for chikungunya viral RNA by real-time reverse transcription polymerase chain reaction in the first week of illness. Obtain convalescent phase samples and test for IgM antibodies if febrile phase samples are negative or if patients present after first week Zika virus infection Recent travel history to (or residence in) an area with reported Zika virus transmission suggests possibility of infection Fever, rash, and myalgias are present in both dengue and Zika, but Zika results in milder illness that lasts 2 to 7 days Pan American Health Organization provisional case definition: Rash (pruritic and maculopapular) plus 2 or more of the following: Arthralgia/myalgia Nonpurulent conjunctivitis Fever (usually lower than 38.5 °C) Periarticular edema