Chikungunya differential diagnosis: Difference between revisions

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Latest revision as of 17:23, 18 September 2017

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Alejandro Lemor, M.D. [2], Alonso Alvarado, M.D. [3]

Overview

Chikunguyna must be differentiated from other diseases that present with flu like symptoms such as fever, headache, fatigue, joint aches or arthralgias, myalgias. Diseases with similar symptoms include dengue fever, influenza, measles, rubella, malaria, and yellow fever.

Differential Diagnosis

The differential diagnosis of chikungunya virus infection varies based on the place of residence, the travel history, and the history of exposures.
Dengue and chikungunya viruses are transmitted by the same mosquitoes (Aedes aegypti and Aedes albopictus) and have similar clinical features.
The two viruses can circulate in the same area and can cause occasional co-infections in the same patient.
Chikungunya virus infection is more likely to cause high fever, severe arthralgia, arthritis, rash, and lymphopenia, while dengue virus infection is more likely to cause neutropenia, thrombocytopenia, hemorrhage, shock, and death.
It is important to rule out dengue virus infection because proper clinical management of dengue can improve the outcome.
In addition to dengue, other considerations include leptospirosis, malaria, rickettsia, group A streptococcus, rubella, measles, parvovirus, enteroviruses, adenovirus, other alphavirus infections (e.g., Mayaro, Ross River, Barmah Forest, O’nyong'nyong, and Sindbis viruses), post-infection arthritis, and rheumatologic conditions.

Shown below is a table summarizing the typical findings of the differential diagnoses of chikungunya.


Disease	Findings
Malaria	Periodic fever and altered level of consciousness
Dengue Fever	Fever and two or more of the following: retro-orbital or ocular pain, headache, rash, myalgia, arthralgia, leucopenia, or hemorrhagic manifestations
Leptospirosis	Severe myalgia localized to calf muscles, conjunctival congestion or subconjunctival hemorrhage, with or without jaundice or oliguria History of contact with contaminated water
Alphaviral infections (Mayaro, Ross River, Barmah Forest, O’nyong nyong, and Sindbis viruses)	Similar clinical presentation as Chikunguyna Travel history and known areas of Mayaro in the Americas
Post-infectious arthritis (including rheumatic fever)	Arthritis of one or more, typically larger joints due to an infectious disease such as Chlamydia, Shigella, and gonorrhea Rheumatic fever is seen more commonly in children as migratory polyarthritis predominantly affecting large joints. Consider antistreptolysin O (ASO) titer and history of sore throat with Jones criteria for rheumatic fever.
Juvenile rheumatoid arthritis	Abrupt onset of fever and subsequent joint involvement in children
Table adapted from Preparedness and Response for Chikungunya Virus: Introduction in the Americas. PAHO © 2011.^[1]

Comparison Between Chikungunya and Dengue Fever Adapted from Clin Infect Dis. (2009) 49(6):942-948.^[2]

Chikungunya should be distinguished from dengue fever, which has the potential for much poorer clinical outcomes, including death. The two diseases can occur together in the same patient.
Shock or severe hemorrhage is very rarely observed in Chikungunya.
In Chikungunya the onset of the disease is more acute and the duration of fever is much shorter.
A maculopapular rash is more frequent in Chikungunya, while petechia may occur in dengue fever.
In Chikungunya the pain is much more pronounced and localized to the joints and tendons in comparison to dengue fever in which the pain is generalized.

**Clinical and laboratory findings of chikunguyna and dengue fever**
Clinical Findings	Chikungunya	Dengue Fever
Fever (>102°F or 39°C)	+++	++
Headache	++	++
Rash	++	+
Arthralgias	+++	+/–
Myalgias	+	++
Shock	—	+/–
Bleeding dyscrasias	+/–	++
Laboratory Findings
Elevated hematocrit	—	++
Leukopenia	++	+++
Neutropenia	+	+++
Lymphopenia	+++	++
Thrombocytopenia	+	+++
Mean frequency of symptoms from studies where the two diseases were directly compared among patient seeking care; +++ = 70-100% of patients; ++ = 40-69%; + = 10-39%; +/– = <10%; — = 0%^[3]^[4]

References

↑ Preparedness and response for Chikungunya virus introduction in the Americas. Washington, DC: Pan American Health Organization CDC, Center for Disease Control and Prevention. 2011. ISBN 978-92-75-11632-6.
↑ Staples, J. Erin; Breiman, Robert F.; Powers, Ann M. (2009). "Chikungunya Fever: An Epidemiological Review of a Re‐Emerging Infectious Disease". Clinical Infectious Diseases. 49 (6): 942–948. doi:10.1086/605496. ISSN 1058-4838.
↑ S. Nimmannitya, S. B. Halstead, S. N. Cohen & M. R. Margiotta (1969). "Dengue and chikungunya virus infection in man in Thailand, 1962-1964. I. Observations on hospitalized patients with hemorrhagic fever". The American journal of tropical medicine and hygiene. 18 (6): 954–971. PMID 5355242. Unknown parameter |month= ignored (help)
↑ Patrick Hochedez, Ana Canestri, Amelie Guihot, Segolene Brichler, Francois Bricaire & Eric Caumes (2008). "Management of travelers with fever and exanthema, notably dengue and chikungunya infections". The American journal of tropical medicine and hygiene. 78 (5): 710–713. PMID 18458301. Unknown parameter |month= ignored (help)

External Links

CDC Chikungunya virus

[PAHO2011-1] Preparedness and response for Chikungunya virus introduction in the Americas. Washington, DC: Pan American Health Organization CDC, Center for Disease Control and Prevention. 2011. ISBN 978-92-75-11632-6.

[StaplesBreiman2009-2] Staples, J. Erin; Breiman, Robert F.; Powers, Ann M. (2009). "Chikungunya Fever: An Epidemiological Review of a Re‐Emerging Infectious Disease". Clinical Infectious Diseases. 49 (6): 942–948. doi:10.1086/605496. ISSN 1058-4838.

[3] S. Nimmannitya, S. B. Halstead, S. N. Cohen & M. R. Margiotta (1969). "Dengue and chikungunya virus infection in man in Thailand, 1962-1964. I. Observations on hospitalized patients with hemorrhagic fever". The American journal of tropical medicine and hygiene. 18 (6): 954–971. PMID 5355242. Unknown parameter |month= ignored (help)

[4] Patrick Hochedez, Ana Canestri, Amelie Guihot, Segolene Brichler, Francois Bricaire & Eric Caumes (2008). "Management of travelers with fever and exanthema, notably dengue and chikungunya infections". The American journal of tropical medicine and hygiene. 78 (5): 710–713. PMID 18458301. Unknown parameter |month= ignored (help)

[1]

[2]

[3]

[4]

@@ Line 5: / Line 5: @@
 ==Overview==
-Chikunguyna must be differentiated from other diseases that present with flu like symptoms such as [[fever]], [[headache]], [[fatigue]], [[joint aches]] or [[arthralgias]], [[myalgias]]. Diseases with similar symptoms include [[dengue]], [[influenza]], [[measles]], [[rubella]], [[malaria]], and [[yellow fever]].
+Chikunguyna must be differentiated from other diseases that present with [[flu]] like symptoms such as [[fever]], [[headache]], [[fatigue]], [[joint aches]] or [[arthralgias]], [[myalgias]]. Diseases with similar symptoms include [[dengue fever]], [[influenza]], [[measles]], [[rubella]], [[malaria]], and [[yellow fever]].
 ==Differential Diagnosis==
-* The differential diagnosis of [[Chikungunya causes|chikungunya virus]] infection varies based on place of residence, travel history, and exposures.
+* The differential diagnosis of [[Chikungunya causes|chikungunya virus]] infection varies based on the place of residence, the travel history, and the history of exposures.
 * [[Dengue]] and chikungunya viruses are transmitted by the same [[mosquitoes]] ([[Aedes aegypti]] and [[Aedes albopictus]]) and have similar clinical features.
 * The two [[viruses]] can circulate in the same area and can cause occasional co-infections in the same patient.
 * [[Chikungunya causes|Chikungunya virus]] infection is more likely to cause high [[fever]], severe [[arthralgia]], [[arthritis]], [[rash]], and [[lymphopenia]], while [[dengue virus]] infection is more likely to cause [[neutropenia]], [[thrombocytopenia]], [[hemorrhage]], [[shock]], and [[death]].
-* It is important to rule out [[dengue virus]] infection because proper clinical management of [[dengue]] can improve outcome.
+* It is important to rule out [[dengue virus]] infection because proper clinical management of [[dengue]] can improve the outcome.
 * In addition to [[dengue]], other considerations include [[leptospirosis]], [[malaria]], [[rickettsia]], [[group A streptococcus]], [[rubella]], [[measles]], [[parvovirus]], [[enteroviruses]], [[adenovirus]], other [[alphavirus]] infections (e.g., Mayaro, [[Ross River virus|Ross River]], Barmah Forest, [[O'nyong'nyong virus|O’nyong'nyong]], and Sindbis viruses), [[Reactive arthritis|post-infection arthritis]], and [[Rheumatology|rheumatologic conditions]].
+Shown below is a table summarizing the typical findings of the differential diagnoses of chikungunya.
 {| style="border: 0px; font-size: 90%; margin: 3px;" align=center
 |+
 ! style="background: #4479BA; width: 120px;" | {{fontcolor|#FFF|Disease}}
-! style="background: #4479BA; width: 400px;" | {{fontcolor|#FFF|Presentation}}
+! style="background: #4479BA; width: 450px;" | {{fontcolor|#FFF|Findings}}
 |-
-| style="padding: 5px 5px; background: #DCDCDC;" | '''Malaria'''
+| style="padding: 5px 5px; background: #DCDCDC;" | '''[[Malaria]]'''
-| style="padding: 5px 5px; background: #DCDCDC;" | Periodicity of fever and alteration of consciousness
+| style="padding: 5px 5px; background: #F5F5F5;" | Periodic [[fever]] and altered level of consciousness
 |-
-| style="padding: 5px 5px; background: #DCDCDC;" | '''Dengue Fever'''
+| style="padding: 5px 5px; background: #DCDCDC;" | '''[[Dengue Fever]]'''
-| style="padding: 5px 5px; background: #DCDCDC;" | Fever and two or more of the following, retro-orbital or ocular pain, headache,rash, myalgia, arthralgia, leucopenia, or hemorrhagic manifestations.
+| style="padding: 5px 5px; background: #F5F5F5;" | [[Fever]] and two or more of the following: retro-orbital or ocular pain, [[headache]], [[rash]], [[myalgia]], [[arthralgia]], [[leucopenia]], or [[hemorrhage|hemorrhagic]] manifestations
 |-
-| style="padding: 5px 5px; background: #DCDCDC;" |'''Leptospirosis'''
+| style="padding: 5px 5px; background: #DCDCDC;" |'''[[Leptospirosis]]'''
-| style="padding: 5px 5px; background: #DCDCDC;" |Severe myalgia localized to calf muscles with conjunctival congestion/or subconjunctival hemorrhage with or without jaundice or oliguria. Consider history of contact with contaminated water
+| style="padding: 5px 5px; background: #F5F5F5;" |Severe [[myalgia]] localized to [[calf muscle]]s, conjunctival congestion or [[subconjunctival hemorrhage]], with or without [[jaundice]] or [[oliguria]]<br> History of contact with contaminated water
 |-
-| style="padding: 5px 5px; background: #DCDCDC;" | '''Alphaviral infections (Mayaro, Ross River, Barmah Forest, O’nyong nyong, and Sindbis viruses)'''
+| style="padding: 5px 5px; background: #DCDCDC;" | '''[[alphavirus|Alphaviral infections]] (Mayaro, Ross River, Barmah Forest, O’nyong nyong, and Sindbis viruses)'''
-| style="padding: 5px 5px; background: #DCDCDC;" | Similar clinical presentation as Chikunguyna; inquire about travel history and known areas of Mayaro in the Americas
+| style="padding: 5px 5px; background: #F5F5F5;" | Similar clinical presentation as Chikunguyna<br> Travel history and known areas of Mayaro in the Americas
 |-
-| style="padding: 5px 5px; background: #DCDCDC;" | '''Post-infectious arthritis (including rheumatic fever)'''
+| style="padding: 5px 5px; background: #DCDCDC;" | '''[[Post-infectious arthritis]] (including [[rheumatic fever]])'''
-| style="padding: 5px 5px; background: #DCDCDC;" | Arthritis of one or more, typically larger joints due to an infectious disease such as Chlamydia, shigella, and gonorrhea.  Rheumatic fever is seen more commonly in children as migratory polyarthritis predominantly affecting large joints.  Consider antistreptolysin O (ASO) titer and history of sore throat with Jones criteria for rheumatic fever
+| style="padding: 5px 5px; background: #F5F5F5;" | [[Arthritis]] of one or more, typically larger [[joints]] due to an infectious disease such as [[Chlamydia]], [[Shigella]], and [[gonorrhea]]<br>  [[Rheumatic fever]] is seen more commonly in children as migratory polyarthritis predominantly affecting large [[joint]]s.<br>
+Consider [[antistreptolysin O]] ([[ASO]]) titer and history of [[sore throat]] with [[Jones criteria]] for [[rheumatic fever]].
 |-
-| style="padding: 5px 5px; background: #DCDCDC;" | '''Juvenile rheumatoid arthritis'''
+| style="padding: 5px 5px; background: #DCDCDC;" | '''[[Juvenile rheumatoid arthritis]]'''
-| style="padding: 5px 5px; background: #DCDCDC;" | Abrupt onset of fever and subsequent joint involvement in children
+| style="padding: 5px 5px; background: #F5F5F5;" | Abrupt onset of [[fever]] and subsequent [[joint]] involvement in children
 |-
-| style="padding: 5px 5px; background: #FFF;" colspan="2"| <SMALL>Table adapted from ''Preparedness and Response for Chikungunya Virus: Introduction in the Americas. PAHO © 2011.''<ref name=PAHO2011>{{cite book | last = | first = | title = Preparedness and response for Chikungunya virus introduction in the Americas | publisher = Pan American Health Organization CDC, Center for Disease Control and Prevention | location = Washington, DC | year = 2011 | isbn = 978-92-75-11632-6 }}</ref></SMALL>
+| style="padding: 5px 5px; background: #FFF;" colspan="2"| <SMALL>Table adapted from ''Preparedness and Response for Chikungunya Virus: Introduction in the Americas. PAHO © 2011.''<ref name=PAHO2011>{{cite book | last = | first = | title = Preparedness and response for Chikungunya virus introduction in the Americas | publisher = Pan American Health Organization CDC, Center for Disease Control and Prevention | location = Washington, DC | year = 2011 | isbn = 978-92-75-11632-6 | url=http://stacks.cdc.gov/view/cdc/21188 }}</ref></SMALL>
 |-
 |}
-==Comparison between Chikungunya and Dengue Fever <small><small><small><small>Adapted from Clin Infect Dis. (2009) 49(6):942-948.<ref name="StaplesBreiman2009">{{cite journal|last1=Staples|first1=J. Erin|last2=Breiman|first2=Robert F.|last3=Powers|first3=Ann M.|title=Chikungunya Fever: An Epidemiological Review of a Re‐Emerging Infectious Disease|journal=Clinical Infectious Diseases|volume=49|issue=6|year=2009|pages=942–948|issn=1058-4838|doi=10.1086/605496}}</ref> </small></small></small></small>==
+==Comparison Between Chikungunya and Dengue Fever <small><small><small><small>Adapted from Clin Infect Dis. (2009) 49(6):942-948.<ref name="StaplesBreiman2009">{{cite journal|last1=Staples|first1=J. Erin|last2=Breiman|first2=Robert F.|last3=Powers|first3=Ann M.|title=Chikungunya Fever: An Epidemiological Review of a Re‐Emerging Infectious Disease|journal=Clinical Infectious Diseases|volume=49|issue=6|year=2009|pages=942–948|issn=1058-4838|doi=10.1086/605496}}</ref> </small></small></small></small>==
 * [[Chikungunya]] should be distinguished from [[dengue fever]], which has the potential for much poorer clinical outcomes, including death. The two diseases can occur together in the same patient.
@@ Line 49: / Line 50: @@
 * In Chikungunya the onset of the disease is more acute and the duration of [[fever]] is much shorter.
 * A [[maculopapular rash]] is more frequent in [[Chikungunya]], while [[petechia]] may occur in [[ dengue fever]].
-* In [[Chikungunya]] the pain is much more pronounced and localized to the [[joints]] and [[tendons]] in comparison of [[dengue fever]], which the pain is generalized.
+* In [[Chikungunya]] the pain is much more pronounced and localized to the [[joints]] and [[tendons]] in comparison to [[dengue fever]] in which the pain is generalized.
 {| style="border: 0px; font-size: 90%; margin: 3px;" align=center
 |+ '''''Clinical and laboratory findings of chikunguyna and dengue fever'''''
-! style="width: 180px;background: #20538D"|{{fontcolor|#FFF| Clinical Findings}}
+! style="width: 180px;background: #4479BA"|{{fontcolor|#FFF| Clinical Findings}}
-! style="width: 120px;background: #20538D"|{{fontcolor|#FFF| Chikungunya}}
+! style="width: 120px;background: #4479BA"|{{fontcolor|#FFF| Chikungunya}}
-! style="width: 120px;background: #20538D"|{{fontcolor|#FFF| Dengue Fever}}
+! style="width: 120px;background: #4479BA"|{{fontcolor|#FFF| Dengue Fever}}
 |-
 |  style="width: 120px;font-weight: bold;background: #DCDCDC"|[[Fever]] (>102°F or 39°C)
-| style="background: #DCDCDC;font-weight: bold; text-align:center"| +++
+| style="background: #F5F5F5;font-weight: bold; text-align:center"| +++
-| style="background: #DCDCDC;font-weight: bold; text-align:center"|++
+| style="background: #F5F5F5;font-weight: bold; text-align:center"|++
 |-
 |  style="width: 120px;font-weight: bold;background: #DCDCDC"| [[Headache]]
-| style="background: #DCDCDC;font-weight: bold; text-align:center"|++
+| style="background: #F5F5F5;font-weight: bold; text-align:center"|++
-| style="background: #DCDCDC;font-weight: bold; text-align:center"|++
+| style="background: #F5F5F5;font-weight: bold; text-align:center"|++
 |-
 |  style="width: 120px;font-weight: bold;background: #DCDCDC"| [[Rash]]
-| style="background: #DCDCDC;font-weight: bold; text-align:center"|++
+| style="background: #F5F5F5;font-weight: bold; text-align:center"|++
-| style="background: #DCDCDC;font-weight: bold; text-align:center"|+
+| style="background: #F5F5F5;font-weight: bold; text-align:center"|+
 |-
 |  style="width: 120px;font-weight: bold;background: #DCDCDC"|[[Arthralgias]]
-| style="background: #DCDCDC;font-weight: bold; text-align:center"|+++
+| style="background: #F5F5F5;font-weight: bold; text-align:center"|+++
-| style="background: #DCDCDC;font-weight: bold; text-align:center"|+/–
+| style="background: #F5F5F5;font-weight: bold; text-align:center"|+/–
 |-
 |  style="width: 120px;font-weight: bold;background: #DCDCDC"|[[Myalgias]]
-| style="background: #DCDCDC;font-weight: bold; text-align:center"| +
+| style="background: #F5F5F5;font-weight: bold; text-align:center"| +
-| style="background: #DCDCDC;font-weight: bold; text-align:center"|++
+| style="background: #F5F5F5;font-weight: bold; text-align:center"|++
 |-
 |  style="width: 120px;font-weight: bold;background: #DCDCDC"|[[Shock]]
-| style="background: #DCDCDC;font-weight: bold; text-align:center"|—
+| style="background: #F5F5F5;font-weight: bold; text-align:center"|—
-| style="background: #DCDCDC;font-weight: bold; text-align:center"|+/–
+| style="background: #F5F5F5;font-weight: bold; text-align:center"|+/–
 |-
 |  style="width: 120px;font-weight: bold;background: #DCDCDC"|Bleeding dyscrasias
-| style="background: #DCDCDC;font-weight: bold; text-align:center"|+/–
+| style="background: #F5F5F5;font-weight: bold; text-align:center"|+/–
-| style="background: #DCDCDC;font-weight: bold; text-align:center"|++
+| style="background: #F5F5F5;font-weight: bold; text-align:center"|++
 |-
-| style="background: #20538D;font-weight: bold; text-align:center"|{{fontcolor|#DCDCDC| Laboratory Findings}}
+| style="background: #4479BA;font-weight: bold; text-align:center"|{{fontcolor|#FFF| Laboratory Findings}}
-| style="background: #20538D"|
+| style="background: #4479BA"|
-| style="background: #20538D"|
+| style="background: #4479BA"|
 |-
 |  style="width: 120px;font-weight: bold;background: #DCDCDC"|[[Hematocrit#Elevated hematocrit|Elevated hematocrit]]
-| style="background: #DCDCDC;font-weight: bold; text-align:center"|—
+| style="background: #F5F5F5;font-weight: bold; text-align:center"|—
-| style="background: #DCDCDC;font-weight: bold; text-align:center"|++
+| style="background: #F5F5F5;font-weight: bold; text-align:center"|++
 |-
 |  style="width: 120px;font-weight: bold;background: #DCDCDC"| [[Leukopenia]]
-| style="background: #DCDCDC;font-weight: bold; text-align:center"|++
+| style="background: #F5F5F5;font-weight: bold; text-align:center"|++
-| style="background: #DCDCDC;font-weight: bold; text-align:center"|+++
+| style="background: #F5F5F5;font-weight: bold; text-align:center"|+++
 |-
 |  style="width: 120px;font-weight: bold;background: #DCDCDC"| [[Neutropenia]]
-| style="background: #DCDCDC;font-weight: bold; text-align:center"|+
+| style="background: #F5F5F5;font-weight: bold; text-align:center"|+
-| style="background: #DCDCDC;font-weight: bold; text-align:center"|+++
+| style="background: #F5F5F5;font-weight: bold; text-align:center"|+++
 |-
 |  style="width: 120px;font-weight: bold;background: #DCDCDC"|[[Lymphopenia]]
-| style="background: #DCDCDC;font-weight: bold; text-align:center"|+++
+| style="background: #F5F5F5;font-weight: bold; text-align:center"|+++
-| style="background: #DCDCDC;font-weight: bold; text-align:center"|++
+| style="background: #F5F5F5;font-weight: bold; text-align:center"|++
 |-
 |  style="width: 120px;font-weight: bold;background: #DCDCDC"|[[Thrombocytopenia]]
-| style="background: #DCDCDC;font-weight: bold; text-align:center"|+
+| style="background: #F5F5F5;font-weight: bold; text-align:center"|+
-| style="background: #DCDCDC;font-weight: bold; text-align:center"|+++
+| style="background: #F5F5F5;font-weight: bold; text-align:center"|+++
 |-
 | style="background: #FFF"; colspan="3"|<small> Mean frequency of symptoms from studies where the two diseases were directly compared among patient seeking care; +++ = 70-100% of patients; ++ = 40-69%; + = 10-39%; +/– = <10%; — = 0%<ref>{{Cite journal
@@ Line 132: / Line 132: @@
 [[Category:Disease]]
-[[Category:Infectious disease]]
 [[Category:Viral diseases]]
 [[Category:Togaviruses]]
 [[Category:Tropical disease]]