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C
hikungunya
epidemic has now spread to most parts of Dakshina Kannada District
and a few deaths have also been reported. Added to this, there are
reports of Dengue, Leptospirosis and malaria from the affected
areas. This has resulted in lot of anxiety and fear among the public
and confusion among the medical fraternity. With co-infections
possible and the season favouring the transmission of all these
infections, it is important to differentiate between these diseases
so that proper treatment can be administered at the earliest and
complications as well as deaths can be prevented. There is a felt
need for a simple algorithm to help in the diagnosis and treatment
of these infections and therefore we suggest the following, based on
the review of the relevant literature[1-14]:
There are many similarities in the
clinical manifestations of chikungunya, dengue and leptospirosis and it may not
be easy differentiating them. Fever, joint pains and rash are common to
chikungunya, dengue and leptospirosis. The fever in chikungunya and dengue
starts abruptly, and remits after 1-2 days and can recur after 1-2 days for
another day or two. Usually, therefore, the fever lasts 5-6 days and subsides on
its own. (However, the present epidemic of chikungunya in the south Asian region
is characterised by a continuous fever lasting 5-6 days, without any remission in
between.) Dengue fever is characterized by severe headache, pain in the muscles
of upper and lower limbs, joint pains and pain on moving the eye balls. In chikungunya, pain and swelling of the joints is a characteristic feature. In
chikungunya, a reddish rash appears on the second or third day over the face and
the chest. The rash in dengue appears on the third or fourth day, predominantly
over the legs and trunk and in some, these rashes may be haemorrhagic (purpuric).
Abrupt, high grade fever with severe aches in the muscles of the limbs and the
back is seen in leptospirosis too. Over the next 4-7 days, the fever continues
and suffusion of eyes, headache, cough etc., may appear. After remitting for 1-2
days, the fever recurs, along with complications like jaundice, kidney failure
and bleeding disorders, resulting in haemorrhagic rashes over the legs. In
malaria, joint pains, muscle pains and rash are not seen and the fever occurs
daily or intermittently on alternate days; some patients may have jaundice.
The diagnosis is helped by simple tests in the blood and urine. The total
leukocyte count is lower in chikungunya and dengue while it is elevated in
leptospirosis. As the kidneys are invariably affected in leptospirosis, urine
examination in these cases would show abnormalities. Malaria can be confirmed by
a peripheral blood smear.
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Algorithm For
Differentiation of Chikungunya, Dengue,.Leptospirosis and
Malaria |
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Atypical symptoms in
chikungunya:
Some of the patients of
chikungunya can have severe pain abdomen, nausea, vomiting, constipation, head
ache and meningism, retro orbital pain, myalgia etc.
Treatment: Chikungunya and dengue are self limiting infections and do not need any
specific treatment. If the fever and/or joint pains are very severe, simple
analgesic like paracetamol can be used. Potent pain killers can cause more harm
than good. Reckless use of NSAIDs can result in gastrointestinal bleeding or
other haemorrhagic manifestations. Prescribing NSAIDs to patients with
pre-existing renal disease or cardiac failure may aggravate the condition.
Steroids have absolutely no role to play in the treatment of acute chikungunya and dengue. If the joint pain and swelling in chikungunya persist
even after 10-15 days, chloroquine can be tried. Leptospirosis is treated with
penicillin or doxycyline.
There is no evidence to show
any beneficial effects of homeopathy or ayurveda in the treatment of chikungunya.
Indications for
Hospitalization: Fatal complications are extremely rare in
chikungunya. Dengue, leptospirosis and falciparum malaria can lead to
complications that may be fatal, if not properly treated. Any patient with the
following signs should be immediately shifted to a tertiary care hospital:
Prevention:
Chikungunya and dengue are
transmitted by the female
Aedes
mosquitoes, malaria is transmitted by the female
Anopheles
mosquitoes and leptospirosis is contracted through water contaminated with the
urine of infected rats.
Aedes mosquitoes bite
during the early hours of morning (6-11am) and evening (5-7pm) and prefer biting
the ankles and legs. Therefore, it is advisable to wear long pants or pyjamas
during these hours and mosquito repellents like DEET can be applied over the
legs or over the clothing, once in the morning and again in the evening.
Aedes mosquitoes breed in clean collections of water and
reduction
of such breeding sources is important.
References:
-
Ann M. Powers, Christopher H. Logue. Changing patterns of chikungunya
virus: re-emergence of a zoonotic arbovirus Available at
http://www.sgm.ac.uk/jgvdirect/82858/82858ft.pdf
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Judith Green-McKenzie. Leptospirosis in Humans
Available at
http://www.emedicine.com/EMERG/topic856.htm
-
Connelly CR, Mores CN, Smartt CT,
Tabachnick WJ.
Chikungunya. Available at
http://edis.ifas.ufl.edu/IN696
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Sathiavathy KA.
Chikungunya fever-Perceptive of Current Epidemic - 2007 Available at
http://www.articleset.com/health_articles_en_Chikungunya-fever-Perceptive-of-Current-Epidemic-2007.htm
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Chhabra M, Mittal V, Bhattacharya D, Rana U, Lal S. Chikungunya fever: A
re-emerging viral infection. Indian J Med Microbiol [serial online] 2008 [cited
2008 Jun 24];26:5-12. Available from:
http://www.ijmm.org/text.asp?2008/26/1/5/38850
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Ashok Swaroop, Arvind Jain, Maniram Kumhar, Naveen Parihar, Sachin
Jain.
Chikungunya Fever. JIACM 2007;8(2):164-8. Available at
http://medind.nic.in/jac/t07/i2/jact07i2p164.pdf
-
MM Parida, SR Santhosh, PK
Dash, PV Lakshmana Rao. Rapid and Real-time Assays for Detection and
Quantification of Chikungunya Virus Available at
http://www.medscape.com/viewarticle/571272
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Mohan, Alladi "Chikungunya
fever: clinical manifestations & management". Indian Journal of Medical
Research. Nov 2006. FindArticles.com. 06 Jul. 2008. Available at
http://findarticles.com/p/articles/mi_qa3867/is_200611/ai_n19198542
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Robert V Gibbons.
Dengue: an escalating problem. BMJ 2002;324:1563-1566 (29 June) Available
at
http://bmj.bmjjournals.com/cgi/content/full/324/7353/1563
-
Carlos CC, Oishi K, Cinco MTDD et
al.
Comparison Of Clinical Features And Hematologic Abnormalities Between Dengue
Fever And Dengue Hemorrhagic Fever Among Children In The Philippines. Am. J. Trop. Med. Hyg.
2005;73(2):435-440. Available at
http://www.ajtmh.org/cgi/content/full/73/2/435
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Sunil Karande, Dipak Gandhi, Madhuri Kulkarni, Renu Bharadwaj, Sae Pol, Jyotsna Thakare, Anuradha De.
Concurrent Outbreak of Leptospirosis and Dengue in Mumbai, India, 2002. Journal of Tropical Pediatrics 2005;51(3):174-181.
Abstract at
http://tropej.oxfordjournals.org/cgi/content/abstract/51/3/174
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Vinod H. Ratageri, T.A. Shepur, P.K. Wari, S.C. Chavan, I.B. Mujahid, P.N.
Yergolkar.
Clinical Profile and Outcome of Dengue Fever Cases. Indian J Pediatr
2005;72(8):705-706. Avalable at
http://medind.nic.in/icb/t05/i8/icbt05i8p705.pdf
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Leptospirosis. Available at
http://www.merck.com/mmpe/sec14/ch174/ch174c.html
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http://www.leptospirosis.org/topic.php?t=50
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