Complications
Most affected pregnant women have a self-limited presentation of the disease. Infected pregnant women may require hospitalisation more frequently than non-infected pregnant women; however, important obstetric outcomes such as obstetric bleeding, rate of C-sections, preterm births, low birth weight, stillbirths, congenital malformations, and newborn admission seemed unaffected by the presence of chikungunya virus infection. Histological study of placentas in infected women failed to show evidence of infection (only 1 infected placenta among 624 studied).[108]
There have been isolated reports of newborns infected in the last trimester of pregnancy and born with neurological or myocardial disease and with haemorrhagic complications.[108]
Haemorrhagic manifestations are uncommon and more subtle than in dengue fever. Cases of gingivorrhagia, epistaxis, haematemesis, and melena have been described in an old series, predominantly in children. Thrombocytopenia, if it occurs, is usually mild.[68]
Anterior uveitis is considered the most common ocular complication. Two variants have been described: a granulomatous and a non-granulomatous form. In some cases, dendritic infiltrates similar to those seen in herpetic keratitis occur. Precipitates and synechia can develop in the anterior chamber of the eye and the intraocular pressure can be elevated. Topical corticosteroids, cycloplegic agents, and medications to relieve intraocular pressure are useful in anterior uveitis. The symptoms are usually short lived.
Conjunctivitis is also common and may be more common than anterior uveitis, but because of a usual mild presentation, is frequently under-reported.
Posterior eye segment involvement is less frequent, but it can occur, including retinitis, choroiditis, and optic neuritis. The fundoscopy and angiography in retinitis resembles herpetic infection with evidence of vascular leakage and areas of capillary non-perfusion. It is suspected that antigenic mimicry between chikungunya virus antigens and host tissue proteins cause a delayed immune response that explains the clinical manifestations. Treatment with systemic steroids is indicated in those situations. The recovery is longer and, in cases of optic neuritis, permanent ocular damage can occur.
Episcleritis, pauveitis, panopthalmitis, bilateral external opthalmoplegia, and various hemianopsias have been described but are unusual.[67]
A systematic review found that more than half of those infected will go on to experience chronic articular symptoms.[107] Patients may develop symmetric polyarthritis that is usually incapacitating and resembles rheumatoid arthritis, but chronic monoarthritis or oligoarthritis can also occur following the acute infection. The course can be continuous or relapsing. Overall, the pain associated with these arthritides tends to decrease with time, but can persist for months and years. Radiological imaging can show focal bony erosions, joint effusions, and bursitis. The clinical manifestations may be associated with persistence of immunoglobulin M (IgM) antibodies and interleukin-6 levels in serum and, occasionally, with positive rheumatoid factor or anti-cyclic citrullinated peptide antibodies.
There is currently no evidence of a definitive link between initial infection and the development of chronic arthritis.[103] However, 3 factors were associated with progression towards chronic disease in one study: age 45 to 59 years (adjusted odds ratio [OR]: 6.4, 95% confidence interval [CI]: 1.8, 22.1) or ≥60 years (adjusted OR: 22.3, 95% CI: 6.3, 78.1), severe initial joint involvement (adjusted OR: 5.5, 95% CI: 2.2, 13.8), and high chikungunya virus IgG titres at the start of the disease (adjusted OR: 6.2, 95% CI: 2.8, 13.2, per 1 unit increase).[5][104][105][106]
A case of carpal tunnel syndrome has been reported.[109]
In addition to rheumatological symptoms, patients may exhibit neuropathic pain affecting the upper and lower limbs, chronic headache, fatigue, asthenia, and depression up to 6 years after the acute infection, in association with significant poor scores in different scales of quality of life (such as the 36-item short-form health survey [SF-36], Arthritis Impact Measurement Scales 2 [AIMS2-SF], and the General Health Questionnaire [GHQ-12]).[67][106]
As other alphaviruses, chikungunya virus may have neurotropic avidity. In experimental models the virus can disseminate to the central nervous system with particular preference for the choroid plexuses and the leptomeninges. Perhaps because of this tendency, the most common neurological complications include meningoencephalitis, meningoencephalo-myeloradiculitis, myeloradiculitis, myelitis, and myeloneuropathy. These manifestations tend to occur during the acute phase of the disease and coincide with the peak of viraemia. Other complications can have a delayed presentation, but usually not beyond 2 weeks of disease onset, including Guillain-Barre syndrome, facial palsy, ophthalmoplegia, and optic neuritis.[58][59][66]
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