Home Approach to Fever Approach to Chikungunya

Approach to Chikungunya

  • Dr. B. Srinivas Kakkilaya, Consultant Physician, Mangalore
  • Dr. M. Chakrapani, Prof. of Medicine, Kasturba Medical College,Mangalore
  • Dr. B. Shantaram Baliga, Professor of Paediatrics, Kasturba Medical College, Mangalore

Chikungunya 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.

Algorithm For Differentiation of Chikungunya, Dengue, Leptospirosis and Malaria

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:

  • Hypotension (drop in blood pressure)
  • Bleeding
  • Breathlessness
  • Altered sensorium
  • Decreased urine output
  • Jaundice
  • Convulsions

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:

  1. 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
  2. Judith Green-McKenzie. Leptospirosis in Humans Available at http://www.emedicine.com/EMERG/topic856.htm
  3. Connelly CR, Mores CN, Smartt CT, Tabachnick WJ. Chikungunya. Available at http://edis.ifas.ufl.edu/IN696
  4. 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
  5. 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
  6. 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
  7. 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
  8. 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
  9. 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
  10. 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
  11. 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
  12. 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
  13. Leptospirosis. Available at http://www.merck.com/mmpe/sec14/ch174/ch174c.html
  14. http://www.leptospirosis.org/topic.php?t=50

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