Clinical Signs and Symptoms of Chikungunya Virus Disease

Clinical presentation

Chikungunya virus disease should be considered in patients with acute onset of fever and polyarthralgia, especially travelers who recently returned from areas with known virus transmission.

The differential diagnosis varies based on place of residence, travel history, and exposures. Dengue, Zika, and chikungunya viruses are transmitted by the same mosquitoes and have similar clinical features. These viruses can circulate in the same area and can cause occasional co-infections in the same patient. Chikungunya virus infection is more likely to cause high fever, severe arthralgia, arthritis, rash, and lymphopenia, while dengue virus infection is more likely to cause neutropenia, thrombocytopenia, hemorrhage, shock, and death. In general, the signs and symptoms of Zika virus are mild, though infections can cause congenital infections. It is important to rule out dengue virus infection because proper clinical management of dengue can improve outcome.

In addition to dengue and Zika, other diagnostic considerations include leptospirosis, malaria, rickettsia, group A streptococcus, rubella, measles, parvovirus, enteroviruses, adenovirus, other alphavirus infections (Mayaro, Ross River, Barmah Forest, o’nyong-nyong, and Sindbis viruses), post-infectious arthritis, and rheumatologic conditions.

Signs and symptoms

The majority of people infected with chikungunya virus become symptomatic. The incubation period is typically 3–7 days (range, 1–12 days).

The disease is most often characterized by acute onset of fever (typically >39°C [102°F]) and polyarthralgia. Joint symptoms are usually bilateral and symmetric and can be severe and debilitating. Other symptoms can include headache, myalgia, arthritis, conjunctivitis, nausea/vomiting, or maculopapular rash. Rare complications include uveitis, retinitis, myocarditis, hepatitis, nephritis, bullous skin lesions, hemorrhage, meningoencephalitis, myelitis, Guillain-Barré syndrome, and cranial nerve palsies.

Persons at risk for severe disease include neonates exposed intrapartum or shortly after birth, older adults (>65 years), and persons with underlying medical conditions (e.g., hypertension, diabetes, or cardiovascular disease).

Clinical assessment

Clinical laboratory findings can include lymphopenia, thrombocytopenia, and elevated creatinine. Elevated hepatic transaminases can be seen with acute infection but are not specific and do not occur frequently enough to be diagnostic.

Outcomes

Acute symptoms typically resolve within 7–10 days. Some patients may have persistence or relapse of rheumatologic symptoms (polyarthralgia, polyarthritis, tenosynovitis) in the months following acute illness. Studies report variable proportions of patients with persistent joint pains for months to years. Mortality is rare and occurs mostly in older adults.

Resources

• CDC Yellow Book Chapter: Chikungunya
• Medscape CDC Expert Commentary: Differentiating Chikungunya from Dengue: A Clinical Challenge