Chikungunya differential diagnosis

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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

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.

Differential Diagnosis

• The differential diagnosis of chikungunya virus infection varies based on place of residence, travel history, and 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 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-infections arthritis, and rheumatologic conditions.

Comparison between Chikungunya and Dengue Fever Adapted from Clin Infect Dis. (2009) 49(6):942-948.

• Chikungunya has to be distinguished from dengue fever, which has the potential for much worse 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 than 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.

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%

References

• CDC Chikungunya virus