Chikungunya Virus Infection

Chikungunya Virus Infection: Rheumatological Manifestations

Clinical Overview

• Chikungunya virus infection can cause acute polyarthralgia or polyarthritis and, in some patients, prolonged inflammatory rheumatic disease.
• Rheumatological manifestations may resemble viral arthritis, rheumatoid arthritis, or spondyloarthritis.

Clinical Phases

Acute Phase: 1 to 2 Weeks

• Polyarthralgia and polyarthritis
  • Sudden onset of severe joint pain and stiffness.
  • Usually symmetric and polyarticular.
  • Commonly affects peripheral joints, including the hands, wrists, ankles, and feet.
  • Joint swelling and inflammation may resemble viral arthritis or acute rheumatoid arthritis.
• Periarticular manifestations
  • Tenosynovitis.
  • Tendinitis.
  • Myalgia.

Post-Acute and Chronic Phase: Weeks to Years

• Chronic inflammatory rheumatism
  • Persistent inflammatory polyarthritis or relapsing and remitting arthralgia and arthritis.
  • May be associated with prolonged morning stiffness, bursitis, and tenosynovitis.
  • The phenotype may resemble seronegative rheumatoid arthritis or spondyloarthritis.
  • Structural damage or deforming erosive arthritis is rare.
• Risk of chronic symptoms
  • Chronic progression occurs in 30% to 60% of infected individuals.
  • Older adults and patients with pre-existing comorbidities have increased risk.

Laboratory Findings

• Acute-phase reactants
  • Erythrocyte sedimentation rate and C-reactive protein may be elevated.
• Autoantibodies
  • Rheumatoid factor and anti-cyclic citrullinated peptide antibodies are typically negative.
  • Low-titer or incidental positivity may occasionally occur.
• Virological and serological testing
  • Chikungunya virus RT-PCR: Use for early diagnostic confirmation during the initial viremic stage.
  • Chikungunya virus IgM and IgG serology: Useful after the acute viremic period to assess post-acute exposure and convalescence.

Management

Acute Phase Management

• Prioritize rest and adequate oral hydration.
• Use paracetamol (acetaminophen) as first-line symptomatic therapy.
• Rule out dengue fever before administering nonsteroidal anti-inflammatory drugs (NSAIDs) because of bleeding risk.
• Start NSAIDs only after dengue infection has been excluded and contraindications are absent.

Persistent or Chronic Phase Management

• Continue NSAIDs when clinically indicated and tolerated.
• Consider short courses of systemic corticosteroids for severe active inflammatory flares.
• Refer patients with persistent objective inflammatory arthritis to rheumatology.
• Disease-modifying antirheumatic drugs (DMARDs)
  • Consider DMARDs for unresolved inflammatory arthritis.
  • Methotrexate has the strongest supporting clinical evidence among the options named in the source note.
  • Hydroxychloroquine may be used as an alternative or adjunct, although supporting evidence is less consistent.

Differential Diagnosis

• Rheumatoid arthritis.
• Reactive arthritis.
• Spondyloarthritis.
• Parvovirus B19 arthritis.
• Hepatitis B viral arthritis.
• Hepatitis C viral arthritis.
• Other viral arthritides, including dengue, Zika, and Ross River virus.

Practical Takeaways

• Consider chikungunya virus infection in patients with abrupt, severe, symmetric peripheral polyarthralgia or polyarthritis.
• Distinguish acute chikungunya virus infection from dengue fever before NSAID treatment.
• Persistent inflammatory arthritis warrants reassessment and possible rheumatology referral.

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