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[1]
The treatment for chikungunya infection is symptomatic and the initial therapy focuses on decrease 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) instituted quickly. 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 |
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Characterized by two of these signs:
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Characterized by two of these signs:
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Management of Symptoms
- Administer Paracetamol 1g PO q6-8h a day 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.
- Tepid sponging can be suggested.
- 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.
Antibiotic Therapy
- Use hydroxychloroquine 200 mg orally once daily or chloroquin phosphate 300 mg orally per day for a period of four weeks in cases where arthralgia is refractory to other drugs.
- Before using chloroquine or related compounds in these doses, the peripheral blood smear examination must be done at least twice to rule out malaria.
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.
Treatment of Complications
Medical Therapy for the Chronic Phase Adapted from Guidelines on Clinical Management of Chikungunya Fever © WHO 2008[1]
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 gap of 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. Complement mediated damage and persistence of the virus in intracellular sanctuaries have been implicated in occasional studies. Destroyed metatarsal head has been observed in patients with persistent joint swelling. Management of osteoarticular manifestations follow the general guidelines given earlier. Since an immunologic etiology is suspected in chronic cases, a short course of steroids may be useful. Care must be taken to monitor all adverse events and the drug should not be continued indefinitely to prevent adverse effects. 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.
Disability due to Chikungunya fever arthritis can be assessed and monitored using one of the standard scales. As discussed above, proper and timely physiotherapy will help patients with contractures and deformities. Nonweight bearing exercises may be suggested.; e. g. slowly touching the occiput (back of the head) with the palm, slow ankle exercises, pulley assisted exercises, milder forms of yoga etc. Surgery may be indicated in severe and disabling contractures. The management plan may be finalized in major hospitals, but the follow-up and long-term care must be done at a domiciliary or primary health centre level. Occupational assistance after detailed disability assessment needs to be provided.
Management of neurological problems
Various neurologic sequelae can occur with persistent chikungunya fever. Approximately 40% of those with CF 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%). Paresethesias, 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 entrapment syndromes like 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, and Pregnable) 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 warrant 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 / emotional problems have been observed in upto 15% cases. These are more likely in persons with pre-morbid disorders and those with a family history of mood disorders. They may take different forms. The emotional and psychosocial issues need individual assessment and have to be considered in the social context of the patient and community. Often patients have inadequate information regarding Chikungunya. 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.