Chronic severe Joint pain of Chikungunya

The rainy season due to the South West Monsoon over the Indian sub continent is over.Epidemic of acute severe joint pain and swellings associated with fever due to Chikungunya infection has also subsided.Now I am seeing more and more patients with Chronic severe joint pain of varying duration, a sequel of Chikungunya infection.

Let me tell you a little more about this virus and the illness it causes in humans.

Chikungunya is a re-emerging, mosquito-borne viral infection causing fever, rash and acute or sudden severe joint pains of several joints.Chikungunya (Chick’-en-GUN-yah) in Swahili an African language meaning “that which contorts or bends up” refers to the contorted (stooped) posture of patients who are afflicted with severe joint pains (arthralgia) the most common feature of the disease.
Chikungunya virus is a single-stranded RNA Alphavirus, from the family Togaviridae. Other Alphaviruses also causing fever, rash and arthralgia, include O’nyong-nyong, Mayaro,Barmah Forest, Ross River and Sindbis viruses. Chikungunya virus is most closely related to O’nyong-nyong, but remains genetically distinct.

The disease was first described by Marion Robinson and W.H.R. Lumsden, following an outbreak along the border between Tanzania(erstwhile Tanganyika) and Mozambique, in1952. Since 1953, the virus has caused outbreaks in Africa and South Eastern Asia, including India, Sri Lanka, Myanmar, Thailand, Indonesia, the Philippines and Malaysia, which are well documented. There is historical evidence that Chikungunya virus originated in Africa and subsequently spread to Asia. Phylogenetic studies support this theory, with Chikungunya virus strains falling into three distinct genotypes based on origin from West Africa, Central/East Africa or Asia.

Chikungunya is transmitted by the bite of the infected Aedes mosquito from an infected person to a healthy person. The disease does not get transmitted directly from human to human (i.e. it is not a contagious disease). In a pregnant woman with Chikungunya there is risk of transmitting the disease to her foetus.
The fever starts usually about 2 to 3 days after the entry of virus into the human body. There will be severe chills and shaking of the body at the onset of fever.At the same time the joint pain and swelling starts.The patient will not be able to move with in minutes of onset of illness.The joints of hands mainly the metacarpo phalangeal and proximal inter phalangeal joints become warm swollen and very painful.Wrist and elbow are also affected to a lesser extend.The joints of ankle,feet and to a lesser extend hip are all affected.
Itchy reddish raised rash is typically seen[70%] when the fever subsides, which in most of my patients was by 3 days.Many patients and Physicians confuse it with drug rash due to allergy to the medicines the patient took for fever and joint pain.
Rash is typically seen on the cheeks, nose and outer part of ears.The ear lobe is typically painful to touch. The rash is also seen over the trunk and limbs with severe itching which lasts for only 2 days. There will be painful swelling of ankle and shin with dark red discoloration. Painful oral ulcers are also seen during this time.Last year I had few patients with enlarged cervical lymph nodes, which disappeared in few days.

Although rare, the infection can result in meningo-encephalitis, especially in newborns and those with pre-existing medical conditions. Pregnant women can pass the infection to their foetus. Severe cases of Chikungunya can occur in the elderly, in very young ones (newborns) and in those who are immuno-compromised.

Chikungunya outbreaks typically result in several hundreds or thousands of cases but deaths are rarely encountered.
Differential diagnosis of Chikungunya includes Dengue and Dengue Haemorrhagic Fever,
O’nyong-nyong virus infection and Sindbis virus infection.
It has been reported that attack rates in susceptible populations may be as high as 40-85 per cent and the ratio of symptomatic to asymptomatic patients is about 1.2:1.

Children are less likely to experience joint pain, but may have other features such as febrile fits, vomiting, abdominal pain and constipation.

The discoloration of the nose usually lasts for months.I call it the seal of Chikugunya as I can identify a person who had Chikungunya in the recent past seeing that seal.
Some patients may remain feverish for some more days. The joint pain become less in few days. In about 60 percent of the patients the ilness including the joint pains last only about a week.They become completly all right with only a little bit of tiredness remaining.
But in about 40% of patients joint pain increases or persists.The chronic joint pain of Chikungunya resembles that of Rheumatoid arthritis. The joints commonly involved are the wrists and the knees.The ankle and smaller joints of feet and hands are also involved.Stiffness of these joints in the morning lasting more than 30 mts is typical. The patient feels better as he/she continues to move the joints.
The joint stiffness and pain lasts for about 3 months in about 30% of patients in my practise. But in an unfortunate 10% it may last indefinitely.

Lab Diagnosis of Chikungunya fever

Virus isolation and PCR techniques are costly and is available in very few centres. Serological diagnosis is possible only after a week of onset by detecting antibodies. As the treatment is mostly symptom specefic diagnosis will not alter patient management much. So the typical triad of fever, acute onset joint pains and rash along with a low white cell count in blood sample is sufficient enough to diagnose Chikungunya fever

Treatment of Chikungunya fever

Paracetamol 10 to 15mg per kg body weight given 3 to 4 times a day reduces the fever.It is needed only in the first 2 to 3 days of illness.

Non Steroidal anti inflammatory agents have to be given liberally to reduce the pain and swelling. This may have to be continued for few weeks in some patients with persistent joint pain. Renal and Gastric safety have to ensured while taking such medicines.
Short course of steroids like Prednisolone also helps in resistant cases.
Other analgesics like Tramadol are also useful.
Disease modifying anti rheumatic agents like Chloroquine have been found useful in some studies.Personally I feel Chloroquine is not of much help as it is a slow acting drug taking almost 3 months to be fully effective.

Most of the patients who turned to alternative systems of medicine for relief came back to me saying there is no relief to pain.Many had to take NSAIDs along with their Ayurvedic and Homeopathic medicines which proved that other systems have nothing much to offer.

In short Chikungunya fever is easy to diagnose but not that easy to treat, but to those who suffer it is pure hell.

Rain

Though late, the South-West monsoon [the main source of Rain for this area] finally have been kind enough to my native state, Kerala.

Until this week, Newspapers were saying that this was the weakest monsoon in recent memory with a 43 percent deficit in rainfall in the first 7 weeks of the season. Power blackouts started [as the major source of Power here is Hydro-electric projects] and fear of failed crops were looming large.
This week everything changed. The sky started pouring and pouring. Even as I type, I can hear the wonderful sound of rain. Newspapers started talking about flash floods and landslips. Let us hope the monsoon will wipe off the rainfall deficit in quick time.

Rain or no Rain,Chikungunya epidemic continues relentlessly. In some families, almost all members are getting affected. I had an opportunity to visit a small town 15 kms away. I went there on invitation of a local Club. They wanted me to give a health education class about chikungunya fever.
When I reached there, the people were not in a mood to listen to a talk. They wanted prescription for medicines so that they can recover fast. Most of them were manual labourers, and the persistent joint pain and swellings were preventing them from working. Some wanted preventive medicines to protect them from the virus. I was helpless. There is no fast cure.The joint pains may last for weeks to months. During that period, they will have to continue taking anti-inflammatory drugs. Also, there is no preventive medicine or vaccine yet. I asked them to take measures to reduce breeding of Aedes mosquito. I also asked them to isolate the patient inside a mosquito net during the time of fever. At that time, maximum number of viruses are there in patient's blood and mosquito bite can easily spread the illness.
My team saw more than 50 patients. Some free medicines were distributed, but nobody was satisfied. As we drove back, my thoughts were on the enormity of physical and economic damage this virus had brought on the society, especially for the poor.

Acute severe joint pain

She was a 30 year old housewife. She was literally carried in to my consulting room by her husband and her mother. She was writhing with agony at each movement of her joints.

She was perfectly all right in the morning.She walked down to the river[which was about 1/2 kilometre away] to bath, came back and made coffee.At that moment,before she could serve coffee her joint pain started with shivering and she had to be carried from kitchen to bedroom.

She had pain in small joints of fingers, wrist,elbow, shoulders,hip,knee and ankles. All those joints were warm. Her temperature was 101F. Rest of the examination was normal.

Yes, this is the classical onset of Chikungunya fever. I send her out in a wheel chair to get admitted.She was given medicines to reduce fever and inflammation of joints.The next day she was sitting happily ready to go home. Her fever has subsided and joint pains less.She will continue to suffer from joint pains for uncertain number of weeks, and thus may need to continue anti inflammatory drugs.



The fever and joint pains in chikungunya infection start so suddenly that some patients are able to tell the exact minute of onset. I still wonder why the onset is so sudden and unexpected.

Thank you Chikungunya

You might be thinking that I am thanking Chikungunya virus for increasing my work and thereby my income.

No you are wrong.

Most people never care to visit a doctor, or check their blood sugar and blood pressure until they get some disease. I am thanking the virus because it helped in detection of type 2 Diabetes in many patients. Also, it helped a few who had undetected high blood pressure.

I know, the patients themselves may not have the same opinion. The pain and suffering they have to endure in Chikungunya fever is enormous. Still there is this compensation of detecting a chronic but manageable disease like Diabetes early before it can produce any serious organ damage.

I am amazed to find that most children of Type 2 Diabetics have not checked their blood sugar even once disregarding the strong family trait for Diabetes. India is now considered as the Diabetic capital of the World with about 40.9 million people estimated to be affected with type 2 Diabetes.Every fifth Diabetic in the World is an Indian.I feel everyone in India should check their blood sugar once every year after the age of 20.If the child is obese or have some other endocrine problem it is better to test even earlier.

Let me end with a happy note. The old lady who stopped insulin on her own and got admitted at 3 am with a blood sugar of 800[DKA ] came for review with her 2 hr after meal Blood sugar value of 170.She is on 30/70 premix Insulin.She promised me never to do that stupidity again.

Chikungunya fever on the rise

Rainy season[monsoon] is here and more and more patients are coming with fever. Many come with sudden rise in temperature, chills, and severe joint pains. As the fever subsides, in few days a itchy skin rash develops. In many, the joint pain and swellings last for weeks to months and sometime years. This is Chikungunya fever.
Chikungunya fever is an easy diagnosis for doctor working in an epidemic setting. After seeing a few patients and following them up it is difficult to miss, but it is a painful diagnosis for the patient. Some who had it last June are still suffering from joint pain and stiffness.

Today I saw about 8 acute chikungunya fever patients and a few chronic joint pain patients due to chikungunya.

More patients now are coming from within 2 kilometres of my clinic/home.
Hope I wont be the next victim.

Virus Attack

My State Kerala on the Southern most part of India is reeling under a Virus attack for last 5 months.It is estimated that more than 5 million people are affected this year.Here is the description of such attack.
A 61 year old Grand mother was waiting for her Grandchildren to come home in their school bus.She walked the 50 metres to the bus stop easily.Suddenly she began shivering and felt severe pain on her knees, ankle and wrists.With in minutes she was not able to move.By the time the Grandchildren came she had to catch a 3 wheeler Taxi[Autorikshaw] to reach home.She had to be carried into the house and by then had developed high fever.
She was admitted in a local hospital were she was given injections for reliving pain and fever.Her fever subsided by 3 days.But on the fourth day she developed reddish rashes over her nose,cheeks, ears, neck and arms.Her shin was swollen reddish and painful.The rashes were mildly itching.She had also few nodular swellings on her neck and armpit.Her joint pain was better with pain killers and she could eat normally.

By the 6th day her rashes had disappeared,also the nodules in her neck.But a dark color remained on her nose Her joint pain was maximum when she got up from bed in the morning.Her moments were limited with out anti-inflammatory medicines.
This state of health continued for almost 3 months.She took all types of treatment including Ayurveda,Homeopathy and Naturopathy with out any success.
By the end of 3 rd month she was able to reduce the dose of anti inflammatory medicines and in another 2 weeks she could stop all medicines and remain pain free.
Which virus is responsible for this attack?