Chikungunya medical therapy

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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

There is no specific antiviral therapy for chikungunya virus. The treatment of the disease is based on decreasing the symptoms and maintain proper hydration. Paracetamol is the drug of choice and treatment should be instituted in all suspect cases without waiting for serological or viral confirmation. All suspected cases should be kept under mosquito nets during the febrile period.

Medical Therapy for the Acute Phase Adapted from Guidelines on Clinical Management of Chikungunya Fever © WHO 2008

The treatment for chikungunya infection is symptomatic and the initial therapy focuses on decreasing the symptoms. It is important to evaluate for other serious conditions (such as dengue, malaria, or bacterial infections) and treat or manage appropriately.

Hydration

Assess hydration and hemodynamic status and provide proper rehydration therapy (preferably oral). It is important to identify patients with severe dehydration, as this patients should be carefully observed and rapid rehydration therapy should be started.

Severe dehydration	Mild or Moderate dehydration
Characterized by two of these signs: Excessive sleepiness or lethargy Sunken eyes Poor fluid intake Dry, parched tongue Reduced skin turgor (very slow skin pinch taking more than 2 sec to retract)	Characterized by two of these signs: Restlessness or irritability Sunken eyes Dry tongue Excessive thirst Slow skin pinch (less than 2 seconds to retract)

Management of Symptoms

• Administer paracetamol 1g orally q6-8h to treat the fever, headache and pain.
• Paracetamol must be used with caution in persons with preexisting underlying serious illnesses.
• Children may be given 50-60 mg/kg/day divided q6-8h.
• Administer antihistamines for itching.
• If inadequate, consider using narcotics or NSAIDs.
• If dengue is suspected, do not use aspirin or other NSAIDs (e.g., ibuprofen, naproxen, toradol) until they have been afebrile ≥48 hours and have no warning signs for severe dengue.
• Persistent joint pain may benefit from use of NSAIDs, corticosteroids, or physiotherapy.

Additional Measures

• Heat may increase/worsen joint pain and is therefore best to avoid during acute stage.
• Mild forms of exercise and physiotherapy are recommended in recovering persons.
• Patients may be encouraged to walk, use their hands for eating, writing and regular isotonic exercises.
• Cold compresses may be suggested depending on the response.
• Exposure to warm environments (morning and evening sun) may be suggested as the acute phase subsides.

Antimalarial Therapy

• Only in cases where arthralgia is refractory to other drugs, antimalarial therapy is recommended.
• Use hydroxychloroquine 200 mg orally once daily or chloroquine phosphate 300 mg orally per day for a period of four weeks
• Before using chloroquine or related compounds in these doses, the peripheral blood smear examination must be done at least twice to rule out malaria.

Treatment of Complications

• Manage serious complications accordingly.
• Manage bleeding disorders with blood components:
  • Platelet transfusions in case of bleeding with platelet counts of less than 50,000 cells/mm³.
  • Fresh frozen plasma, or vitamin K injections if INR is more than 2.
• Treat hypotension with fluids and if needed use inotropics.
• Manage acute renal failure with dialysis.
• Contractures and deformities should be managed with physiotherapy or surgery
• Neuropsychiatric problems with specialist care and the appropriate medication.
• Patients with myopericarditis or meningoencephalitis may require intensive care with regular monitoring,inotropicsupport or mechanical ventilation.

Medical Therapy for the Chronic Phase Adapted from Guidelines on Clinical Management of Chikungunya Fever © WHO 2008

Management of osteoarticular problems

• Osteoarticular problems seen with Chikungunya fever usually subside in one to two weeks’ time.
• In approximately 20% cases, they disappear after a few weeks.
• In less than 10% cases, they tend to persist for months.
• In about 10 % cases, the swelling disappears; the pain subsides, but only to reappear with every other febrile illness for many months. Each time the same joints get swollen, with mild effusion and symptoms persist for a week or two after subsidence of the fever.
• Destroyed metatarsal head has been observed in patients with persistent joint swelling.
• Since an immunologic etiology is suspected in chronic cases, a short course of steroids may be useful.
• Even though NSAIDs produce symptomatic relief in majority of individuals, care should be taken to avoid renal, gastrointestinal, cardiac and bone marrow toxicity.
• Cold compresses have been reported to lessen the joint symptoms.

Management of neurological problems

• Various neurologic sequelae can occur with persistent chikungunya fever.
• Approximately 40% of patients with chikungunya infection will complain of various neurological symptoms but hardly 10% will have persistent manifestations.
• Peripheral neuropathy with a predominant sensory component is the most common (5-8%).
• Paresthesias, pins and needles sensations, crawling of worms sensation and disturbing neuralgias have all been described by the patients in isolation or in combination.
• Worsening or precipitation of carpal tunnel syndrome has been reported in many patients.
• Motor neuropathy is rare.
• Occasional cases of ascending polyneuritis have been observed as a postinfective phenomenon, as seen with many viral illnesses.
• Seizures and loss of consciousness have been described occasionally, but a causal relationship is yet to be found.
• Anti-neuralgic drugs (amitryptyline, carbamazepine, gabapentin) may be used in standard doses in disturbing neuropathies.
• Ocular involvement during the acute phase in less than 0.5% cases as described above may lead to defective vision and painful eye in a small percentage.
• Progressive defects in vision due to uveitis or retinitis may require treatment with steroids.

Management of dermatological problems

• The skin manifestations of Chikungunya fever subside after the acute phase is over and rarely require long term care.
• However worsening of psoriatic lesions and atopic lesions may require specific management by a qualified specialist.
• Hyperpigmentation and papular eruptions may be managed with Zinc oxide cream and/or Calamine lotion.
• Persistent non-healing ulcers are rare.
• Scrotal and aphthous- like ulcers on the skin and intertriginous areas may be managed by saline compresses, and topical or systemic antibiotics if secondarily infected.

Management of psycho-somatic problems

• Neuro-psychiatric and emotional problems have been observed in up to 15% cases.
• These are more likely in persons with pre-morbid disorders and those with a family history of mood disorders.
• The emotional and psychosocial issues need individual assessment and have to be considered in the social context of the patient and community.
• Broadly, psychosocial support and reassurance may solve some of the problems.
• A well thought about plan for community support, occupational and social rehabilitation may hold the key for success.

References

• CDC Chikungunya virus