Case history
Case history #1
A 62-year-old woman with history of diabetes mellitus and hypertension presents after a trip to Puerto Rico, complaining of a 4-day history of fever associated with chills and severe arthralgia and myalgia affecting her hands, elbows, knees, and hips. The pain is disabling and prevents her from walking without help. On exam, she has a faint maculopapular rash affecting her torso and extremities. There is also swelling of both hands. Her complete blood count and chemistry are unremarkable, except for lymphopenia and hyperglycemia. Serologic test for dengue is negative. Immunoglobulin M (IgM) for chikungunya virus is detected in a sample obtained on day 8 of illness. The patient is treated with acetaminophen and hydration. Her symptoms abate 2 weeks after starting. Three weeks later she has a bout of joint aches with similar distribution as the original presentation, but without fever or rash. Her reactivated symptoms resolve after 2 days and do not return.
Case history #2
A healthy 25-year-old woman in the third trimester of pregnancy presents after a trip to Réunion Island in the Indian Ocean. She has had symptoms for 3 days, including fever, intense headache, and severe arthralgias, predominantly in the lower extremities. She has aphthous ulcers in the mouth and gingivorrhagia, there is a mild macular rash in the torso, and mild edema in the lower extremities. Serology for chikungunya virus at the time of presentation is negative; however, a convalescent titer later turns positive. The patient is admitted for observation. Her course is complicated with obstetric hemorrhage and premature delivery. The newborn has no signs of infection but 3 days after birth, both reverse transcription polymerase chain reaction and IgM serologic tests are positive.
Other presentations
Along with fever, polyarthritis is the most common manifestation of infection. Any joint can be affected, but distal peripheral joints are more commonly affected than the axial skeleton. The involvement is usually symmetric and can be debilitating and prevent ambulation. The majority of patients recover without sequelae; however, a subgroup of patients develop recurrent or persistent arthralgias or arthritis, often associated with morning stiffness. These manifestations can last for months to years. Sometimes patients may fulfill the American College of Rheumatology criteria for rheumatoid arthritis.[4] Some patients may present with neuropathic-type pain.
The course of the disease can be continuous or relapsing.[5] Diffuse erythroderma is also described. Other presentations, including vesicular and purpuric lesions, have been described, but less often. Centrofacial hyperpigmentation and ulcers in skin folds may also be present. Pruritus is common. Edema of face and extremities has also been described.
Neurologic, ocular, or hemorrhagic manifestations are unusual.
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