Distinguishing patients with laboratory-confirmed chikungunya from dengue and other acute febrile illnesses, Puerto Rico, 2012–2015

Abstract

Chikungunya, a mosquito-borne viral, acute febrile illness (AFI) is associated with polyarthralgia and polyarthritis. Differentiation from other AFI is difficult due to the non-specific presentation and limited availability of diagnostics. This 3-year study identified independent clinical predictors by day post-illness onset (DPO) at presentation and age-group that distinguish chikungunya cases from two groups: other AFI and dengue. Specimens collected from participants with fever ≤7 days were tested for chikungunya, dengue viruses 1–4, and 20 other pathogens. Of 8,996 participants, 18.2% had chikungunya, and 10.8% had dengue. Chikungunya cases were more likely than other groups to be older, report a chronic condition, and present <3 DPO. Regardless of timing of presentation, significant positive predictors for chikungunya versus other AFI were: joint pain, muscle, bone or back pain, skin rash, and red conjunctiva; with dengue as the comparator, red swollen joints (arthritis), joint pain, skin rash, any bleeding, and irritability were predictors. Chikungunya cases were less likely than AFI and dengue to present with thrombocytopenia, signs of poor circulation, diarrhea, headache, and cough. Among participants presenting <3 DPO, predictors for chikungunya versus other AFI included: joint pain, skin rash, and muscle, bone or back pain, and absence of thrombocytopenia, poor circulation and respiratory or gastrointestinal symptoms; when the comparator was dengue, joint pain and arthritis, and absence of thrombocytopenia, leukopenia, and nausea were early predictors. Among all groups presenting 3–5 DPO, pruritic skin became a predictor for chikungunya, joint, muscle, bone or back pain were no longer predictive, while arthritis became predictive in all age-groups. Absence of thrombocytopenia was a significant predictor regardless of DPO or comparison group. This study identified robust clinical indicators such as joint pain, skin rash and absence of thrombocytopenia that can allow early identification of and accurate differentiation between patients with chikungunya and other common causes of AFI.

Chikungunya Manifestations and Viremia in Patients Who Presented to the Fever Clinic at Bangkok Hospital for Tropical Diseases During the 2019 Outbreak in Thailand

“…Without diagnostics, chikungunya infection is difficult to distinguish from other acute febrile illnesses caused by common arboviruses like dengue viruses or Zika virus. Previous reports have described that chikungunya cases have higher viremia than dengue and Zika (40). In contrast, others have reported that dengue cases have lower leucopenia and thrombocytopenia compared to cases of chikungunya or Zika (71).…”

“…Chikungunya virus causes similar clinical manifestations during the acute phase that could mimic other arboviruses, and there are no widely available point-of-care rapid diagnostics (43,64,65). For these reasons, clinicians working in endemic regions and those treating returning travelers are challenged with diagnosing chikungunya infection (40,(66)(67)(68).…”

“…A subset of individuals exhibit atypical manifestations, and some develop a chronic course of illness (36)(37)(38). Based on clinical and laboratory profiles, it is difficult for clinicians to distinguish chikungunya infection from other circulating pathogens such as dengue and Zika viruses (39,40). To overcome this obstacle, researchers at the Mahidol-Osaka Center for Infectious Diseases at Mahidol University in Thailand, in collaboration with the Department of Viral Infections at Osaka University in Japan, have developed a novel prototype rapid point-of-care immunochromatography test kit that identifies suspected chikungunya cases based on detection of the E1 antigen (41,42).…”

Chikungunya Manifestations and Viremia in Patients Who Presented to the Fever Clinic at Bangkok Hospital for Tropical Diseases during the 2019 Outbreak in Thailand

“…A subset of individuals exhibit atypical manifestations, and some develop a chronic course of illness [ 36 , 37 , 38 ]. Based on clinical and laboratory profiles, it is difficult for clinicians to distinguish chikungunya infection from other circulating pathogens such as dengue and Zika viruses [ 39 , 40 ]. To overcome this obstacle, researchers at the Mahidol-Osaka Center for Infectious Diseases at Mahidol University in Thailand, in collaboration with the Department of Viral Infections at Osaka University in Japan, have developed a novel prototype rapid point-of-care immunochromatography test kit that identifies suspected chikungunya cases based on detection of the E1 antigen [ 41 , 42 ].…”

Oral lesions are frequent in patients with Chikungunya infection

“… 9 Of note, others haemorrhagic manifestations, such as skin and mucosal bleeding, were considered positive predictor of Chikungunya infection among patients with suspected arbovirus infection. 10 …”