Immunoglobulin Therapy in a Patient With Severe Chikungunya Fever and Vesiculobullous Lesions

Abstract

Chikungunya virus (CHIKV) is an emerging arbovirus whose transmission has already been reported in several countries. Although the majority of individuals acutely infected with CHIKV appear to become asymptomatic, reports showing the occurrence of atypical and severe forms of the disease are increasing. Among them, the neurological and skin manifestations require medical attention. Treatment of CHIKV infection is almost symptomatic. In this sense, we report the case of a 56-years-old man who presented fever, headaches, paresthesia and pain in the right arm with visible red spots on the skin starting 30 days before Hospital admission. Tests determined Chikungunya infection and excluded other co-morbidities. Disease evolved with edema in hands and feet and extensive hemorrhagic bullous lesions on the skin of upper and lower limbs. Variations in hematological counts associated with liver dysfunction determined this patient's admission to the Intensive Care Unit. Then, he received intravenous antibiotic and immunoglobulin therapy (400 mg/Kg/day for the period of 5 days) with total recovery from the lesions after 10 days of follow-up. A general improvement in blood cell count and successful wound healing was observed. After discharge, no other clinical sign of the disease was reported until nowadays. This case reports for the first time the successful administration of intravenous immunoglobulin therapy to a patient with severe atypical dermatological form of Chikungunya Fever without any associated comorbidity.

Epidermolisis por chikungunya por transmisión autóctona en República Dominicana. Caso atípico y severo en un recién nacido (RN)

“…El uso de inmunoglobulina endovenosa se ha propuesto como una alternativa en el manejo de pacientes con enfermedad atípica y severa de piel, ya que se ha utilizado en pacientes con Síndrome de Guillain-Barré asociados al CHIKV, con buenos resultados. 22 Nuestro caso correspondió a transmisión autóctona, ya que en el RN se considera transmisión vertical cuando el cuadro clínico inicia entre el tercer y séptimo día de edad, con un promedio de 4 días. De igual modo, porque la enfermedad se presentó a los 24 días de nacido, desarrollando epidermólisis severa, con distress respiratorio y una respuesta adecuada al manejo, cuya evolución fue satisfactoria y solo presentó manchas hipo e híper crómicas secundarias a las lesiones ampollosas generalizadas durante el período agudo de la enfermedad, en la etapa de recuperación y curación.…”

Clinicopathologic features between different viral epidemic outbreaks involving the skin

“…Chikungunya distinctive features beyond aspecific fever, headaches and general malaise are prominent joint-related symptoms, and peculiar dermatologic manifestations. 106 , 107 , 108 , 109 , 110 , 111 , 112 , 113 , 114 , 115 A maculopapular eruption occurs in about 1/3 of patients, 106 3-5 days after general symptoms onset, but a more pathognomonic sign is the facial melanosis, especially the nose pigmentation, which might support retrospective diagnosis of chikungunya fever. 102 , 108 , 109 , 110 Acral edema, intertriginous hyperpigmentation and aphthae-like lesions, purpuric lesions accentuated in photo exposed areas are other quite striking findings.…”

“…A vesicle-bullous eruption, becoming hemorrhagic, and ulcers in most severe cases has also been reported. 111 , 112 Bullous lesions and hyperpigmentation over the axilla, perioral and genital areas were reported in infants from India. 103 Atypical muco-cutaneous manifestations, with ulcers occurrence in the scalp, abdomen, genital and perianal region were report in newborn and infants in Colombia.…”

Clinicopathologic features among different viral epidemic outbreaks involving the skin

“…Chikungunya distinctive features beyond aspecific fever, headaches and general malaise are prominent joint-related symptoms, and peculiar dermatologic manifestations. 106 , 107 , 108 , 109 , 110 , 111 , 112 , 113 , 114 , 115 A maculopapular eruption occurs in about 1/3 of patients, 106 3-5 days after general symptoms onset, but a more pathognomonic sign is the facial melanosis, especially the nose pigmentation, which might support retrospective diagnosis of chikungunya fever. 102 , 108 , 109 , 110 Acral edema, intertriginous hyperpigmentation and aphthae-like lesions, purpuric lesions accentuated in photo exposed areas are other quite striking findings.…”

“…A vesicle-bullous eruption, becoming hemorrhagic, and ulcers in most severe cases has also been reported. 111 , 112 Bullous lesions and hyperpigmentation over the axilla, perioral and genital areas were reported in infants from India. 103 Atypical muco-cutaneous manifestations, with ulcers occurrence in the scalp, abdomen, genital and perianal region were report in newborn and infants in Colombia.…”