Chikungunya virus infection

Patients have increased metabolic demands, and appropriate hydration and proper nutrition should be maintained.[75]Centers for Disease Control and Prevention. Treatment and prevention of chikungunya virus disease. May 2024 [internet publication]. https://www.cdc.gov/chikungunya/hcp/treatment-prevention/index.html ​

Rest is important.[75]Centers for Disease Control and Prevention. Treatment and prevention of chikungunya virus disease. May 2024 [internet publication]. https://www.cdc.gov/chikungunya/hcp/treatment-prevention/index.html ​ Patients may need to have time off work or be confined to less strenuous activities.

Excessive movement of acutely inflamed joints should be avoided; however, strict immobilisation is not indicated. Rest with passive mobilisation of joints and encouragement of isometric muscle contractions may be helpful. Physiotherapy and occupational therapy may be indicated during the recovery phase.

Warm or cold compresses and baths with warm or cold water may provide relief of joint symptoms.[48]Brito CAA, Marques CDL, Falcão MB, et al. Update on the treatment of musculoskeletal manifestations in chikungunya fever: a guideline. Rev Soc Bras Med Trop. 2020;53:e20190517. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7405653 http://www.ncbi.nlm.nih.gov/pubmed/32756797?tool=bestpractice.com ​[76]Direction Generale de la Sante. National recommendations on the management of Chikungunya [in French]. Nov 2014 [internet publication]. http://www.sante.gouv.fr/IMG/pdf/2014-Chikungunya-recommandations_SPILF_2014.pdf ​

When there are doubts about the diagnosis or concerns about co-infection with other viruses, and in cases of persistent fever or atypical manifestations, infectious disease consultation is appropriate. In cases of meningitis or meningoencephalitis, a neurology consultation is indicated.

Treatment recommended for ALL patients in selected patient group

Paracetamol is the treatment of choice for the management of fever and pain during the acute phase.[75]Centers for Disease Control and Prevention. Treatment and prevention of chikungunya virus disease. May 2024 [internet publication]. https://www.cdc.gov/chikungunya/hcp/treatment-prevention/index.html ​

Caution should be used among patients consuming over-the-counter medicines (as they may also contain paracetamol) and among patients with liver disease (including alcohol users).

Regular dosing is recommended over ‘when required’ dosing.

Additional treatment recommended for SOME patients in selected patient group

Aspirin and systemic NSAIDs should be used with caution during the initial weeks of disease, and not until other infections have been excluded, because they can worsen haemorrhagic manifestations (uncommon in chikungunya virus infection, but of concern in patients who may have a co-infection with dengue).[75]Centers for Disease Control and Prevention. Treatment and prevention of chikungunya virus disease. May 2024 [internet publication]. https://www.cdc.gov/chikungunya/hcp/treatment-prevention/index.html ​ Aspirin and other salicylates may also trigger Reye's syndrome, a potentially lethal steatohepatitis associated with cerebral oedema among patients with viral syndromes; therefore, aspirin should be avoided in children and adolescents. However, if other conditions have been ruled out, and there is persistence of symptoms beyond 3 to 4 weeks, a trial of an appropriate oral NSAID can be justified. There is no specific NSAID recommended. Recommendations below were based on expert opinion. Whichever NSAID is chosen, its efficacy should be re-evaluated in 7 to 10 days and another agent tried if there has been no response. Treatment should not exceed 3 to 4 weeks. NSAIDs and aspirin should not be administered to pregnant women.

Tramadol and opioid analgesics (e.g., hydrocodone/paracetamol, oxycodone, morphine) can be considered in select cases when pain does not respond to NSAIDs. Morphine should be reserved for patients with very severe pain. If hydrocodone/paracetamol is selected, paracetamol monotherapy should be ceased. Opioids should be used for the minimum period possible and de-escalated promptly to either an NSAID or paracetamol.

Regular dosing is recommended over ‘when required’ dosing.

Additional treatment recommended for SOME patients in selected patient group

If joint pain does not respond to analgesics, neuropathic pain may be present.

If the patient is found to have a neuropathic component to their pain (confirmed using the Douleur Neuropathique 4 [DN4] questionnaire), amitriptyline or gabapentin are indicated.[48]Brito CAA, Marques CDL, Falcão MB, et al. Update on the treatment of musculoskeletal manifestations in chikungunya fever: a guideline. Rev Soc Bras Med Trop. 2020;53:e20190517. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7405653 http://www.ncbi.nlm.nih.gov/pubmed/32756797?tool=bestpractice.com ​​

Gabapentin is preferable in older patients as amitriptyline may cause sedation. It is also preferred in patients with a history of arrhythmias. Dose should be started low and increased gradually according to response.

These agents may be used in conjunction with other analgesics.

Response should be assessed after 15 days.

Additional treatment recommended for SOME patients in selected patient group

Treatment with corticosteroids is indicated in cases of encephalopathy, uveitis, optic neuritis, acute demyelinating encephalomyelitis, or neuropathy.[58]Tandale BV, Sathe PS, Arankalle VA, et al. Systemic involvements and fatalities during Chikungunya epidemic in India, 2006. J Clin Virol. 2009 Oct;46(2):145-9. http://www.ncbi.nlm.nih.gov/pubmed/19640780?tool=bestpractice.com [59]Ganesan K, Diwan A, Shankar SK, et al. Chikungunya encephalomyeloradiculitis: report of 2 cases with neuroimaging and 1 case with autopsy findings. AJNR Am J Neuroradiol. 2008 Oct;29(9):1636-7. http://www.ajnr.org/content/29/9/1636.long http://www.ncbi.nlm.nih.gov/pubmed/18566010?tool=bestpractice.com [66]Murthy J. Chikungunya virus: the neurology. Neurol India. 2009 Mar-Apr;57(2):113-5. http://www.bioline.org.br/pdf?ni09036 http://www.ncbi.nlm.nih.gov/pubmed/19439837?tool=bestpractice.com [67]Mahendradas P, Avadhani K, Shetty R. Chikungunya and the eye: a review. J Ophthalmic Inflamm Infect. 2013 Feb 11;3(1):35. http://www.ncbi.nlm.nih.gov/pubmed/23514031?tool=bestpractice.com

Topical corticosteroids, cycloplegic agents, and medications to relieve intraocular pressure are useful in anterior uveitis.[67]Mahendradas P, Avadhani K, Shetty R. Chikungunya and the eye: a review. J Ophthalmic Inflamm Infect. 2013 Feb 11;3(1):35. http://www.ncbi.nlm.nih.gov/pubmed/23514031?tool=bestpractice.com

Consult specialist for guidance on choice of agent(s) and dose.

Additional treatment recommended for SOME patients in selected patient group

NSAID-embedded patches or gels may provide relief in cases of sinovitis, bursitis, arthralgia, and arthritis. Topical, as opposed to oral/systemic, NSAIDs are acceptable early in the course of the condition. Ideally, treatment should not last longer than 2 weeks.

Additional treatment recommended for SOME patients in selected patient group

When bursitis or arthritis is associated with fluid collections that are not responsive to other measures, aspiration and infiltration with a corticosteroid can be used. Ideally, this treatment should not be offered more than once.

For patients who develop symptoms resembling rheumatoid arthritis at least 12 weeks after the disease onset, DMARDs are indicated, particularly in patients who test positive for the presence of anti-cyclic citrullinated peptide antibodies.

The DMARD of choice is hydroxychloroquine. Methotrexate is a second-line option.[48]Brito CAA, Marques CDL, Falcão MB, et al. Update on the treatment of musculoskeletal manifestations in chikungunya fever: a guideline. Rev Soc Bras Med Trop. 2020;53:e20190517. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7405653 http://www.ncbi.nlm.nih.gov/pubmed/32756797?tool=bestpractice.com ​ While there are a lack of data comparing hydroxychloroquine and methotrexate, hydroxychloroquine is often recommended first-line as it has a better adverse effect profile compared with methotrexate, which is associated with hepatotoxicity and myelotoxicity. Hydroxychloroquine is not recommended in patients with glucose-6-phosphate dehydrogenase deficiency due to an increased risk of haematological adverse effects. If pain persists after an 8-week trial of hydroxychloroquine, sulfasalazine may be added. If combination treatment is not effective, the patient can be switched to methotrexate. Folic acid is recommended in combination with methotrexate to decrease the risk of adverse effects. Alternative choices include leflunomide and sulfasalazine monotherapy.​[60]Bouquillard E, Combe B. A report of 21 cases of rheumatoid arthritis following Chikungunya fever. A mean follow-up of two years. Joint Bone Spine. 2009 Dec;76(6):654-7. http://www.ncbi.nlm.nih.gov/pubmed/19945329?tool=bestpractice.com [76]Direction Generale de la Sante. National recommendations on the management of Chikungunya [in French]. Nov 2014 [internet publication]. http://www.sante.gouv.fr/IMG/pdf/2014-Chikungunya-recommandations_SPILF_2014.pdf [79]Gaujoux-Viala C, Gossec L, Cantagrel A, et al. Recommendations of the French Society for Rheumatology for managing rheumatoid arthritis. Joint Bone Spine. 2014 Jul;81(4):287-97. https://www.sciencedirect.com/science/article/pii/S1297319X14001419?via%3Dihub http://www.ncbi.nlm.nih.gov/pubmed/24986683?tool=bestpractice.com [80]Ganu MA, Ganu AS. Post-chikungunya chronic arthritis-our experience with DMARDs over two year follow up. J Assoc Physicians India. 2011 Feb;59:83-6. http://www.ncbi.nlm.nih.gov/pubmed/21751641?tool=bestpractice.com

These medications should only be prescribed by a specialist and treatment managed under the supervision of a rheumatologist. Clinical and laboratory monitoring is required before and during treatment. Patients should be assessed every 6 weeks. The visual analogue scale is often used to assess pain severity. Treatment should be ceased when the patient is pain free.

Patients with symptoms resembling a spondyloarthropathy 12 or more weeks after disease onset should be treated preferentially with NSAIDs. Treatment should not exceed 3 to 4 weeks.

Methotrexate and sulfasalazine can be also be used as second-line alternatives. Biological agents such as a tumour necrosis factor-alpha inhibitor (e.g., infliximab) should only be used in refractory cases. Folic acid is recommended in combination with methotrexate to decrease the risk of adverse effects.

DMARDs should only be prescribed by a specialist and treatment managed under the supervision of a rheumatologist. Clinical and laboratory monitoring is required before and during treatment. Patients should be assessed every 6 weeks. The visual analogue scale is often used to assess pain severity. Treatment should be ceased when the patient is pain free.

For patients with undifferentiated polyarthritis 12 or more weeks after disease onset, NSAIDs are the treatment of choice. Treatment should not exceed 3 to 4 weeks.

An alternative option is a corticosteroid. Oral therapy is preferred; however, parenteral therapy can be considered in more severe cases.

Refractory cases can be treated with methotrexate. Folic acid is recommended in combination with methotrexate to decrease the risk of adverse effects. It should only be prescribed by a specialist and treatment managed under the supervision of a rheumatologist. Clinical and laboratory monitoring is required before and during treatment.

Patients should be assessed every 6 weeks. The visual analogue scale is often used to assess pain severity. Treatment should be ceased when the patient is pain free.