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Scourge of chikungunya
View(s):By Kumudini Hettiarachchi
Two weeks before her wedding, she was horrified to find her face, the area around her nose, disfigured by a heavy black patch. When she rushed to see a doctor that she learnt that it was a long-term effect of the troublesome chikungunya infection, which would pass after a while.
The virus which causes chikungunya, spread by the same mosquito Aedes which brings about dengue, has not just wide and varied symptoms but also different long-term effects on people, says Prof. Manoji Pathirage, Professor in Medicine, University of Peradeniya & Consultant Physician at the Peradeniya Teaching Hospital.
Small joints affected by the infection
Giving a little history, she says that chikungunya hit Tanzania in the 1960s and by 2004 it was causing disease in the world’s tropical belt. Spreading in 2006, 2007 and 2008, it peaked in 2007. Now it is raging once again in Sri Lanka causing much debilitation among patients.
Prof. Pathirage says that the initial symptoms of chikungunya include fever, body aches & pains (myalgia), joint pains (arthralgia), arthritis (inflammation with redness and swelling of joints) and a rash which could sometimes be itchy. There could also be a severe headache and muscle spasms.
Black patch around the nose due to the infection
While pointing out that initially there could be high fever for 2-3 days, she zeroes-in on the rash which is usually red and could mimic the measles rash and could appear anywhere on the body including the hands, legs and face. Some patients get the rash on the 3rd or 4th day, while in others it may appear after a week. Some may have the rash with the fever and others when the fever has subsided.
Regarding joint pain and swelling, this Physician explains that it is the small joints of the hands and wrists and the lower limb joints such as the ankles and those in the feet that are mainly affected. She has treated a significant number of patients who were also suffering with bi-lateral (both) knee joint pains. Some even get shoulder, neck and hip pain. Even after the fever subsides, a large number of patients are left with marked ankle and feet pain, while the swollen and tender joints also persist for about a month. In some, when medications are over, the symptoms recur.
Prof. Pathirage says that when patients consult them with these symptoms, as deadly dengue is also doing the rounds, they would rule out dengue by doing a dengue antigen test. This is because in dengue too there is a platelet drop and they need to know whether it is dengue or chikungunya, as the treatment of the latter could make dengue worse.
The red rash caused by the infection
Once the doctors have this information, if it is chikungunya, as there are no anti-virals for this infection, they would advise patients to stay well-hydrated, drinking at least 2.5-3 litres of liquid a day. The fever and pain would be managed with paracetamol and if there is gastritis and nausea, the relevant medications would be prescribed. Medications such as gabapentin would be given if a patient complains of “hariyta kakuldanawa” (a burning sensation in the feet).
Prof. Manoji Pathirage
In the first few days of the infection, if the patient is suffering from severe pain and fever and his/her platelet count is normal, non-steroidal anti-inflammatory medications (NSAIDs) would be given.
There is also a place for steroids in the case of arthritis and enthesitis (an inflammation of enthuses or the sites where tendons and ligaments attach to bone), she adds.
| Unexpected long-term effects ‘Chick rash’ is what happened to the bride-to-be, says Prof. Manoji Pathirage, explaining some of the unexpected long-term effects of chikungunya. “After recovering from acute illness, she got black spots over the nasal area. This is facial hypermelanosis or hyperpigmentation with the darkening of the skin due to more melanin (a skin pigment produced by melanocytes) deposits collecting there,” she says, explaining that in some patients there is a tendency for heavy peeling of the skin especially of the palms and feet but not necessarily restricted to these areas. The virus’s effect on the skin could also impact a person’s hair, with heavy loss of hair, she says. According to Prof. Pathirage some of the long-term effects of chikungunya include a psychological impact, reducing the work capacity of people affected. Referring to immune-mediated complications (when the virus causes the immune system to go awry), she says that while joint pain can mimic rheumatoid arthritis, some can get arthritis later. The other complications could be if the virus affects the central nervous system which may manifest as Guillain-Barré syndrome (impacting the peripheral nerves causing numbness and muscle weakness); encephalitis & meningitis (inflammation of brain tissue); and transverse myelitis (inflammation across a segment of the spinal cord which could cause paralysis of the lower limbs). Chikungunya could also affect any organ, triggering involvement of the heart, lungs, liver, kidney, gastrointestinal (GI) tract and eyes. Meanwhile, there would be chronic arthritis in about 60% of the patients and even carpal tunnel syndrome (pain, numbness, tingling and weakness in the hand and wrist). If expectant mothers get chikungunya, there could be vertical transmission to the baby, she says, stressing that prevention is the best answer.
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