clinical aspects and management of the...
TRANSCRIPT
Clinical aspects and management of the typical uncomplicated acute
chikungunya
Bernard-Alex Gaüzère
Intensive Carte Unit, Centre Hospitalier Universitaire
La Réunion (France)
Visiting professor, University of Bordeaux (France)
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Chikungunya: a double disease
• Arbovirosis
– Acute
– Epidemic
– Linked to the spread of the vector
– Media staged-event
• Alphavirosis
– Rheumatism
– Chronic
– « Endemic »
– Under estimated
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3187
3187
2902
2517
1665
1159
974
797
626
0 500 1000 1500 2000 2500 3000 3500
Arthralgies
Fièvre
Myalgies
Céphalées
Eruption
Nausées-vomissements
Signes respiratoires ou ORL
Diarrhée
Signes hémorragiques
Classical presentation in Réunion & Mayotte:
Main clinical signs
Acute phase (D 0-10) : typical presentation
• Incubation: 2-4 days (1-12 days)
• High fever (90-96%): 2-3 days
• Arthralgia / arthritis (95-100%)
– Generalised, intenses, disabling
• Rash (40-75%)
– Cutaneous maculopapular
– Limited bleeding (5-11%)
• Lymphadenopathy: neck +++, 2 – 3 days
• Headache
• 5 – 12% asymptomatic cases
Skin rash: typical presentation
5 – 12% asymptomatic cases
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Acute chikungunya: facial oedema
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Acute chikungunya
7Generalised hyperhemia: 2-3 days
Palmar erythema(B. Lamey and Coll.)
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Enanthema(B. Lamey and Coll.)
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Always present in case of skin rash with gingival bleeding
Auricular pseudo-chondritis(coll. F. Simon)
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Eye involvment (J. Roche)
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Acute phase: joint involvement
• Arthralgias / arthritis (95-100%)
– Bilateral, symetrical
– > 10 joints groups
– Hands, feets: wrists, ankles++
– Incapaciting +++
• Peri-articular oedema
• Tenosynovitis
– Wrists, ankles
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Acute phase: joint involvement
13Peri-articular swelling and articular effusion
Acute phase: arthritis
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Acute phase: arthritis
(E. Javelle)
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Acute phase: multifocal pains
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Atypical forms
• Definiton: other than fever and arthralgia
• Digestives (40%)
– Nausea, vomiting, diarrhea, abdominal pain
• Ocular
– Optical nevritis, retinitis
• Cutaneous
– Hyper or hypopigmentation (nose, limbs): acute, subacute
– Mucosae ulcers (moutn, genital)
– Bullous dermatosis
– Post-Chik induced psoriasis
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Keratodermia(B. Lamey and coll.)
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Dysidrosis(B. Lamey and coll.)
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Purpura(B. Lamey and coll.)
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Deep vesiculous rash(B. Lamey and coll.)
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Bubles
Aphtoïd ulcerations(B. Lamey and coll.)
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Psoriasis ± purpura (B. Lamey and coll.)
23Psoriasis simplex
Hyperpigmentation(B. Lamey and coll.)
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Hyperpigmentation(B. Lamey and coll.)
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Erythema nodosum(B. Lamey and coll.)
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Biological and clinical markers
InoculationClinical
symptoms
D-2 à D-4 D0 D4-D7 D15
IgM
IgG
Viral RNA
(RT-PCR)
Incubation time (3 to 7 days)
Sudden onsetArthralgias, rash, feverHeadaches, buccal erosions
Management of uncomplicated acute
chikungunya (Day 0-10)
• There is currently no effective antiviral treatment for chik.
• Treatment is therefore purely symptomatic and is based onnon-salicylate analgesics and non-steroidal anti-inflammatorydrugs.
• Synergistic efficacy was reported between interferon-α andribavirin on chikungunya virus in vitro.
• A trial in Réunion and in animal model failed to confirm theefficacy of chloroquine during the acute phases of the chikinfection.
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Management of uncomplicated acute
chikungunya (Day 0-10)
• No antiviral drug
• Rest & no work
• Symptomatic treatment
– Anti-pyretics, pain killers (up to class 3)
– NSAI not indicated: iatrogenic, dangerous if dengue
– No steroids: rebound effect, no mid term benefit
– Oral (or IV) rehydration, given the clinical features
– Caution: overdosages (Paracetamol) and sides effects: traditional
medicine (Noni juice…)
• Altruistic isolation of suspected cases
– Mosquito nets, mosquito repellents
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Protection of viremic patients from Aedes
bites
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Individual protection against mosquitos
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Management of uncomplicated subacute
chikungunya (Day 10-90)
• Rapid improvement
• Or chronic evolution
• Clinical relapse (82%) and worsening at month 2-3
– Rhumatism
– Vascular troubles
– Chronic fatigue and depression
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Conclusion
• Several lessons can be drawn from the outbreaks of chik inthe Indian Ocean islands.
• Clinical manifestations are highly variable and may be moresevere than previously reported
• Economic development does not protect countries fromvector-borne diseases (eg, West Nile virus in the USA, anddengue fever in Rio or Singapore);
• On the contrary, modern lifestyles may amplify an epidemicthrough travel, population ageing, and production of solidwaste that can shelter Aedes mosquitoes.
• There is no satisfactory treatment for the acute phase.
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