Myriad cutaneous presentation of chikungunya fever during recent epidemic in Gujarat: a case study of 124 cases

INTRODUCTION

Chikungunya literally means “that which bends up” in the Makonde language of Tanzenia, due to severe incapacitating arthritis associated with the disease. Chikungunya fever (CF) is caused by Chikungunya virus (CHIK V) (Family- Togaviridae, Genus- Alphavirus) which is transmitted by the bite of infected Aedes aegypti and Aedes albopicus mosquitoes.¹ The first epidemic in the world occurred in Tanzania in 1952-53.² In India, the first outbreak occurred in Kolkata in 1963.³ Since then, it periodically re-emerged in India in the states of Andhra Pradesh, Karnataka, Maharashtra, Madhya Pradesh, Tamil Nadu, Rajasthan, Kerala and Gujarat.

Incubation period of chikungunya is 2-4 days, with range of 1-12 days.¹ It presents with abrupt onset of fever as high as 39- 40C with chills. The temperature may remit and recur after a gap of 4-10 days, resulting in “biphasic or saddle back” fever. Constitutional features like headache, retrobulbar pain, sore throat and malaise can be there. The arthralgia is polyarticular, migratory and predominantly affects small joints of hands, wrists, ankle and feet with lesser involvement of large joints. Patients with mild arthralgia become symptom free within few weeks but more severe cases may develop chronic rheumatoid form. Hematologic manifestations consist of leukopenia, thrombocytopenia and lymphocytosis or lymphopenia.

Cutaneous manifestations may range from maculo-popular rash, pigmentary changes, palmo-planter desquamation, vesiculobullous lesions, aphthous like ulcers in intertriginous areas, vasculitis lesions, ecchymosis/purpura, pruritus, erythema multiforme like lesions to exacerbation of pre-existing dermatoses. We conducted this study to determine incidence of various cutaneous manifestations of chikungunya fever during recent epidemic.

METHODS

We included 124 patients who presented to our outpatient department, department of DVL, P.D.U. Govt. Medical College and Hospital, Rajkot, voluntarily due to their skin problems or referred patients from other department during recent epidemic from July- October 2017. Patients presented with abrupt onset of fever, arthralgia or other constitutional symptoms and cutaneous manifestations were included. A detailed history with a special emphasis on the nature of fever, joint pain and appearance of the skin lesion was taken. Clinical examination was performed and the findings were recorded. Drug reactions and other viral exanthema were ruled out by careful history, clinical examination and investigations. Serology (ELISA test) for chikungunya was done in all the cases. Laboratory investigations like complete blood counts, renal function test, S. Electrolytes, liver function test and urinalysis were done as and when required.

RESULTS

A total 124 cases of chikungunya with cutaneous manifestations were enrolled. Females 68 (54.83%) outnumbered males 56 (45.16%). Maximum number of cases 41 (33.06%) were in 21- 30 years of age group followed by 27 (21.77%) in 31-40 years of age group (Table 1). Youngest patient was of 4 months and oldest was of 70 years.

Cutaneous manifestations are shown in Table 2. The most common cutaneous presentation was morbilliform rash (Figure 1) observed in 78 (62.9%) cases which predominated in females (61.53%). All the patients had morbilliform eruption during acute illness and subsided without sequale. Pigmentary changes were seen in 11 cases (8.87%) of which 9 patients had characteristic nasal hyperpigmentation (Figure 2). Aphthous like ulcers were seen in groin/ axilla in 11 patients (8.87%), 90.9% of them were males and 1 female patient had similar presentation (Figure 3) which is not reported in other studies.¹ Vesicular and purpuric eruption was found in 9 (7.25%) cases of which 2 were infants. Toxic epidermal necrolysis like peeling without mucosal involvement was observed in 5 (4.03%) adult patients (Figure 4). These findings are not reported in adults. Other manifestations noted were generalised pruritus in 4 (3.22%), palmar/planter desequamationin in 2 (1.61%), urticaria in 1 (0.8%) and palmar erythema in 1 (0.8%) cases. Exacerbations of existing dermatoses were documented. One patient of chronic plaque psoriaisis presented with erythroderma. Other one of Still’s disease had aggravation of arthritis and maculo-papular rash after chikungunya fever.

DISCUSSION

Chikungunya is a re-emerging viral infection clinically characterized by an acute febrile illness with incapacitating polyarthralgia, headache, vomiting, sore throat, conjunctivitis and varied cutaneous manifestations. The disease is usually self-limiting, sometimes can be fatal. Supportive care and rest is sufficient in most of the cases.

Chikungunya can affect all age group as seen in our study with youngest patient of 4 months of age to oldest of 70 years of age. Females were outnumbered males (M: F- 1: 1.21) similar to study carried out by Riyaz et al while both sexes were equally affected in study carried out by Bandopadhayay et al.^4,5

The most common cutaneous manifestation described in chikungunya is erythematous maculo-papular rash affecting the trunk, limbs and face. Erythematous macules were the most common presentation in our study observed in 62.9% which developed abruptly during acute illness after 2- 3 days of fever involving mainly trunk and limbs with islands of normal skin. In most of the cases, skin lesions subsided without any sequelae but some cases it lead to palmo-planter desequamation. Pruritus can be associated. Similar observations were made by studies done by Riyaz et al and Bhat et al.^4,6

Different types of pigmentation have been reported in chikungunya. It was the most common presentation in study done by Inamdar et al and the second most common in our study.⁷ Nasal hyperpigmentation was characteristically seen in 7.25%. This is specific for chikungunya fever, usually not observed in other viral exanthems. Retrospective diagnosis of chikungunya can also be made by observation of nasal hyperpigmentation. Other patterns of pigmentation were melasma-like over the face and generalised pigmentation. Pigmentary changes could be post inflammatory or due to increase adrenocortical activity secondary to infection.⁷ An increased melanin disruption triggered by virus has also been postulated.

Multiple aphthae-like lesions affecting intertriginous areas, axillae and scrotum were seen in 8.87%. These aphthae like ulcers were not reported in women in other studies.¹ In our study we reported similar presentation in one female patient. These ulcers are usually multiple, tender, punched out and can be associated with inguinal lymphedenopathy. We reported inguinal lymphedenopathy in two patients.

Vesicular eruption can occur probably by viral replication in the epidermis causing focal necrosis, ballooning degeneration or nuclear disruption. These vesiculo-bullous eruptions are mostly seen in infants according to other studies.^8,9 In our study, we reported vesiculo-bullous eruption in 7 adults and 2 infants.

Flaccid bullae with superficial peeling resembling TEN (Figure 4) with striking mucosal sparing was observed in 5 adult patients. Confluent pattern was observed in 2 patients and rest had spotty pattern. There was no history of drug intake prior to such lesions. Riyaz et al noted TEN like peeling in infants but no study has reported similar findings in adult patients.⁴

Other manifestations reported were generalised pruritus observed in 4 (3.22%) cases and urticaria in 1 (0.8%) case. Isolated palmer/planter desequamation was seen in 2 (1.61%) cases, which was mild and had occurred after subsidence of acute illness. Palmar erythema was noted in 1 (0.8%) case.

Exacerbation of existing dermatoses has been well documented in chikungunya fever.^4,7,10 One psoriatic patient who was in remission developed erythroderma after chikungunya fever, while another patient of Still’s disease had aggravation of symptoms like arthritis and maculo-papular rash following chikungunya fever in our study.

CONCLUSION

Wide variety of cutaneous manifestations can occur in chikungunya fever, so it should be suspected in patients presented with fever, arthralgia and various cutaneous changes. Usually it runs a benign course but can have significant morbidity due to persistent arthritis or can be proven fatal due to acute renal failure. Vesicular eruption and TEN like peeling can contribute to significant morbidity. Morbilliform rash is the most common manifestation of chikungunya we encountered in our study. Nasal hyperpigmentation can be considered as specific clinical marker of chikungunya which can even help to diagnose chikungunya retrospectively. Vesicular eruption and TEN like peeling can occur in adult patients, which was unreported entity. Female patients too can have aphthae like ulcers in intertriginious areas.

As there is no specific treatment available against chikungunya virus, vector control measures like elimination of breeding places and use of insect repellents, mosquito nets, full sleeved clothes may help in minimizing the transmission and reduce disease burden in the community.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the institutional ethics committee

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