Chikungunya

Chikungunya was first detected and confirmed in TANZANIA in 1952-53 by isolation of chikungunya virus. This virus was first isolated from patients with suspected dengue fever. Chikungunya is a local word in Makonde language, meaning doubling up owing to excruciating joint pains. In India the first outbreak was in Kolkata in 1963-64 and another in Chennai in 1965 which gave rise to 3, 00,000 cases in Chennai city alone. Later there was no epidemic of chikungunya for 40 long years.

The disease has reappeared after 40 long years. In 2005-06 again there was an outbreak in 151 districts in 8 states like Andaman and nicobar island, AP, Delhi, Maharashtra, Gujarat, Karnataka, MP, Tamil Nadu and Kerala. More than 1.25 million cases have been reported in the country with majority of cases from Karnataka and Maharashtra. The latest outbreak was in coastal Karnataka in the month of April- May 2008 affecting a large number of people. Affected people are still having residual joint pains, non specific enthesopathy and musculoskeletal ache and pains.

AGENT:

Chikungunya virus is a member of the genus aphavirus in the family Togaviridae.

MODE OF TRANSMISSION:

Only by infected mosquito bite-female Aedes egypti. Air borne spread not yet confirmed.

VECTOR:

Female AEDES EGYPTI mosquito is responsible for the spread, can also be transmitted by culex and mansonia mosquitoes. Aedes mosquitoes are smaller than other mosquitoes and they breed only in artificially stagnated fresh water, i.e. water tanks, water stored flower pots, buckets filled with water, etc. Aedes mosquitoes are easily distinguished by white stripes on a black body. Because of the striped or banded character of their legs, they are sometimes referred to as ‘tiger mosquitoes’.

Characteristics of Aedes mosquitoes–

1. IT BITES ONLY IN THE DAY TIME.
2. Aedes bites at a time many persons and then rests. (Female anopheles bites at a time only one person and then rests). Hence the spread of Chikungunya is faster than Malaria.
3. Aedes breeds only in artificial accumulations of water in and around human dwellings such as water found in discarded tins, broken bottles, fire buckets, coconut shells, earthern pots, tree holes,clean, fresh water. The other mosquitoes like Culex breeds in dirty water collections, stagnant drains, septic tank and Mansonia mosquitoes breeds on breeds on ponds and lakes containing certain aquatic plants.

Incubation period: 4-7 days.

CLINICAL FEATURES:

Symptoms – Usually symptoms differ from place to place / patient to patient depending upon the age and stamina of the sufferer.

Severity – more in old age, undernourished people, people with existing joint diseases.

First day:
Sudden onset with fever, chills, cephalalgia, anorexia, lumbago and severe arthralgia.

Second – third day:
Fever continues, joint pain affecting hand joints (MCP), foot, toes, painful to touch. Unable to move. In 60-80 % of patients have a morbilliform rash occasionally with purpura on the trunk and limbs.

Third – fifth day:
Fever subsides. Skin lesion may recur. Joint pain increases especially small joints of hands and feet. Early morning stiffness, swelling and redness of the joints may be noted. The intensity of the joint pain varies from person to person. Patients with preexisting joint diseases may have severe manifestations compared to the people with normal joints.

After one week:
Some recover. But the recovery will not be like common viral fever. The joint pain will especially ankle pain, swelling, sensitive feet etc.

Other features: (not in all patients)
Adenopathy, bleeding form the nose, redness of the eyes, headache, vomiting or diarrhea, subungual hemorrhage, mouth ulcers.

General condition improves within one week in majority of the patients.

Clinical classification of cases:

1. Acute case- less than 7 days.
2. Sub acute case- 7-14 days.
3. Chronic case- More than 14 days.

Dermatological Manifestation in Chikungunya

• Freckle like pigmentation over face.
• Vesicobullous lesions in children.
• Nasal blotchy erythema.
• Loss of appetite, coated tongue,
• Skin rash- maculopapular, most intense on trunk and limbs and may desquamate.
• Hyperpigmentation in central part of face. Some times pigmentation of Nose.
• Pruritus.
• Erythematous rashes of body and limbs.
• Scrotal ulcers.

Musculoskeletal Manifestation
Patients are divided into 3 grades according to the functional efficiency
Grade I: active, mobile and independent.
Grade II: Not active, mobile.
Grade III: Bed ridden and dependent for ADLs.

1. Arthropathy/ Enthesopathy/ Tendinitis: Ankle and foot, Knee, spine, Wrist, shoulder, Phalanges, Tendoachillis, Hamstrings, Evertors of foot, Extensor pollicis brevis and Abductor Pollicis Longus and Rotator cuff.

2.Functional and ambulation limitations : Bathing, Grooming, Dressing are the most common activities of Daily living affected.
Washing clothes and grinding the most common instrumental activities of daily living affected.

3. Migratory polyarthralgia.

Neuro Psychiatric problems:

1. Persistent Somatoform Pain disorder- Never neglect symptoms, therapeutic dialogue (communication- verbal and nonverbal, listening and touch. Address fear, emotional conflicts and psychological problems. Encourage gradual reentry in to routine work.
2. Adjustment disorder: subjective distress and emotional disturbance interfering with social functioning, arising in a period of adaptation to a serious physical illness.
3. Depression: mostly in women, sadness of mood, lack of intrest, easy fatiguability, insomnia, loss of appetite, hopelessness and worthlessness, lasting for more than two weeks .
4. Insomnia: Common symptom in acute phase, lasts for 2 days to one week. Management of pain and reassurance alone needed in most of the cases.

LABORATORY INVESTIGATIONS.

1. BLOOD: Few patients develop Leucopenia. In some there will be thrombocytopenia. But thrombocytopenia is not severe as in Dengue.
2. SEROLOGICAL TESTS: Detection of antibodies to chikungunya virus in the blood. IgM ( ELISA)
3. Antigen detection with molecular technique like Polymerase chain reaction. ( PCR)

Differential diagnosis with differentiating features:

1. Other Viral fever- no residual joint pains and short convalescence.
2. Malaria – Blood test for MP( flourescent/smear), intermittent fever.
3. Dengue fever- Low total count, palatelet count, altered BT,CT, PTT( in Hemorrhagic complications.
4. Leptospirosis- altered liver function tests, rise in serum creatinine ( in complicated), Urine- RBC’S.
5. Urinary tract infection – Urine micro will reveal more number of pus cells.

PREVENTION OF CHIKUNGUNYA:
Prevention of mosquito breeding:

• Controlling the breeding sites of mosquito by avoiding water stagnation in and around houses.
• Keep covered, water stored in buckets and tanks
• Water from flower pots should be changed at least once a week
• Fogging and killing them (for adult mosquito) especially in daytime since they are active during daytime.
• Using bleaching powder and other pesticides / chemicals in stored water (to clear larva and pupa).
• All containers storing water should be covered with a tight lid
• Water stored in barrels, drums etc should be replaced by fresh stock (at least) once a week
• Discarded container-like objects like tyres, coconut shells, bottles, etc should be disposed off or destroyed.
• Water fountains should be kept dry once a week
• Rain water collected on terraces/roofs should be cleared (at least) once a week
• Mosquitoes can be controlled by using net, mesh, coils, liquids, sprays, creams, etc.

Prevention of Chikungunya through Homoeopathy:
The concept of Preventive strategy in Homeopathy is as old as the Homeopathic system of medicine itself. Many of the Homoeopathic literatures like Organon of medicine, Lesser writings, M L Tyler’s drug pictures will give us a definite and clear strategic plan of epidemic disease preventive and curative management. Hahenmann’s guidelines regarding the selection of genus epidemicus should be followed strictly.
Homoeopathic medicines are useful in prevention and also in reducing the severity of the illness and have some disease modifying action if taken well in advance. Homoeopathic preventive medicines are given for 5-7 days and need to repeat these medicines after 3 weeks. Constitutional medicine will give protection for a longer period.

HOMOEOPATHIC MANAGEMENT OF CHIKUNGUNYA AND POST CHIKUNGUNYA ARTHRALGIA:

ACUTE PHASE: Less than 7 days.
Apis, Arnica, Bell,Benzoid acid, Bry, Cham, Colchicum, Eupat, Formica, Gaultheria, Hymosa, ledum, Guiacum, , Rhus tox.

SUBACUTE PHASE: 7-14 days
Actea spicata, Caulophyllum, Phytolocca, Rhododendron, Rhus tox

CHRONIC PHASE- after 2 weeks.
Bry, Calc, Calc flour, Ledum, Kalmia, Medo, Puls, Ruta

Post chikungunya enthesopathy: Pain in soles, feet, Heel tendons, tennis elbow etc..: Arnica, Formica, Kali bich, Phyto, Rhodo.

Therapeutics for post chikungunya arthralgia with few joints affection:

1. Pain in the hands- Caulophyllum, Colchicum, Rhux tox.
2. Pain in the fingers – Caulophyllum, Rhodo,
3. Pain in the finger joints- Ant crud, Caulo, Caust.
4. Pain in the ankle- Ledum pal, Guaiacum, Oleum j, Verat vir,
5. Pain in the foot- Rhus tox, Hepar, Ledum, Ruta.
6. Pain in the joints of feet- Bry, Calc, Guaicum, Staphy
7. Pain in the sole- Caust.
8. Pain in the heel – Ammon Mur, Aranea diadema, Calc, Puls, Rhodo.
9. Pain in the toes- Benz acid, Caulo, Phyto, Rhodo, Rhus tox
10. Swelling of multiple joints- Act spicata, Bell, Bry, Colch, Hep, Ledum, Sulph.
11. Swelling of the wrist joint- Act spicata, Apis, Lact acid, Rhus tox.
12. Swelling of the hand- Apis, colch,
13. Swelling of the fingers- Act spic, Apis, Bry, Kali bich, Phyto, Rhus tox
14. Swelling of the finger joints- Bry, Calc, Caulo, Cham, Lactic acid, Lyco, Nit acid, Phyto, Rhus tox.
15. Swelling of the ankle- Apis, Chel, Kalm, Med
16. Swelling of foot- Apis, Ars, Bry, caust, Led, Lyco, Med, Puls, Silicea.

Dermatological manifestations:
Ars alb, Apis, Bovista, Puls, Natrum mur, Rhus tox, Sulph.

Neuropsychiatric manifestations:
Somatoform pain disorder: Chamomilla, Moschus, Lac caninum, Ignatia, Natrum Mur.