clinical aspects and management of the ......classical presentation in réunion & mayotte: main...

Clinical aspects and management of the typical uncomplicated acute

chikungunya

Bernard-Alex Gaüzère

Intensive Carte Unit, Centre Hospitalier Universitaire

La Réunion (France)

Visiting professor, University of Bordeaux (France)

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Chikungunya: a double disease

• Arbovirosis

– Acute

– Epidemic

– Linked to the spread of the vector

– Media staged-event

• Alphavirosis

– Rheumatism

– Chronic

– « Endemic »

– Under estimated

3

3187

3187

2902

2517

1665

1159

974

797

626

0 500 1000 1500 2000 2500 3000 3500

Arthralgies

Fièvre

Myalgies

Céphalées

Eruption

Nausées-vomissements

Signes respiratoires ou ORL

Diarrhée

Signes hémorragiques

Classical presentation in Réunion & Mayotte:

Main clinical signs

Acute phase (D 0-10) : typical presentation

• Incubation: 2-4 days (1-12 days)

• High fever (90-96%): 2-3 days

• Arthralgia / arthritis (95-100%)

– Generalised, intenses, disabling

• Rash (40-75%)

– Cutaneous maculopapular

– Limited bleeding (5-11%)

• Lymphadenopathy: neck +++, 2 – 3 days

• Headache

• 5 – 12% asymptomatic cases

Skin rash: typical presentation

5 – 12% asymptomatic cases

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Acute chikungunya: facial oedema

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Acute chikungunya

7Generalised hyperhemia: 2-3 days

Palmar erythema(B. Lamey and Coll.)

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Enanthema(B. Lamey and Coll.)

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Always present in case of skin rash with gingival bleeding

Auricular pseudo-chondritis(coll. F. Simon)

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Eye involvment (J. Roche)

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Acute phase: joint involvement

• Arthralgias / arthritis (95-100%)

– Bilateral, symetrical

– > 10 joints groups

– Hands, feets: wrists, ankles++

– Incapaciting +++

• Peri-articular oedema

• Tenosynovitis

– Wrists, ankles

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Acute phase: joint involvement

13Peri-articular swelling and articular effusion

Acute phase: arthritis

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Acute phase: arthritis

(E. Javelle)

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Acute phase: multifocal pains

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Atypical forms

• Definiton: other than fever and arthralgia

• Digestives (40%)

– Nausea, vomiting, diarrhea, abdominal pain

• Ocular

– Optical nevritis, retinitis

• Cutaneous

– Hyper or hypopigmentation (nose, limbs): acute, subacute

– Mucosae ulcers (moutn, genital)

– Bullous dermatosis

– Post-Chik induced psoriasis

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Keratodermia(B. Lamey and coll.)

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Dysidrosis(B. Lamey and coll.)

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Purpura(B. Lamey and coll.)

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Deep vesiculous rash(B. Lamey and coll.)

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Bubles

Aphtoïd ulcerations(B. Lamey and coll.)

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Psoriasis ± purpura (B. Lamey and coll.)

23Psoriasis simplex

Hyperpigmentation(B. Lamey and coll.)

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Hyperpigmentation(B. Lamey and coll.)

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Erythema nodosum(B. Lamey and coll.)

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Biological and clinical markers

InoculationClinical

symptoms

D-2 à D-4 D0 D4-D7 D15

IgM

IgG

Viral RNA

(RT-PCR)

Incubation time (3 to 7 days)

Sudden onsetArthralgias, rash, feverHeadaches, buccal erosions

Management of uncomplicated acute

chikungunya (Day 0-10)

• There is currently no effective antiviral treatment for chik.

• Treatment is therefore purely symptomatic and is based onnon-salicylate analgesics and non-steroidal anti-inflammatorydrugs.

• Synergistic efficacy was reported between interferon-α andribavirin on chikungunya virus in vitro.

• A trial in Réunion and in animal model failed to confirm theefficacy of chloroquine during the acute phases of the chikinfection.

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Management of uncomplicated acute

chikungunya (Day 0-10)

• No antiviral drug

• Rest & no work

• Symptomatic treatment

– Anti-pyretics, pain killers (up to class 3)

– NSAI not indicated: iatrogenic, dangerous if dengue

– No steroids: rebound effect, no mid term benefit

– Oral (or IV) rehydration, given the clinical features

– Caution: overdosages (Paracetamol) and sides effects: traditional

medicine (Noni juice…)

• Altruistic isolation of suspected cases

– Mosquito nets, mosquito repellents

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Protection of viremic patients from Aedes

bites

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Individual protection against mosquitos

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Management of uncomplicated subacute

chikungunya (Day 10-90)

• Rapid improvement

• Or chronic evolution

• Clinical relapse (82%) and worsening at month 2-3

– Rhumatism

– Vascular troubles

– Chronic fatigue and depression

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Conclusion

• Several lessons can be drawn from the outbreaks of chik inthe Indian Ocean islands.

• Clinical manifestations are highly variable and may be moresevere than previously reported

• Economic development does not protect countries fromvector-borne diseases (eg, West Nile virus in the USA, anddengue fever in Rio or Singapore);

• On the contrary, modern lifestyles may amplify an epidemicthrough travel, population ageing, and production of solidwaste that can shelter Aedes mosquitoes.

• There is no satisfactory treatment for the acute phase.

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