Clinical Evaluation & Disease

Modes of Transmission

Chikungunya virus is primarily transmitted to humans through the bites of infected mosquitoes, predominantly Aedes aegypti and Aedes albopictus. Humans are the primary host of chikungunya virus during epidemic periods. Blood-borne transmission is possible; cases have been documented among laboratory personnel handling infected blood and a health care worker drawing blood from an infected patient. Rare in utero transmission has been documented mostly during the second trimester. Intrapartum transmission has also been documented when the mother was viremic around the time of delivery. Studies have not found chikungunya virus in breast milk and there have been no reports to date of infants acquiring chikungunya virus infection through breastfeeding. Because the benefits of breastfeeding likely outweigh the risk of chikungunya virus infection in breastfeeding infants, mothers should be encouraged to breastfeed even if they are infected with chikungunya virus or live in an area with ongoing virus transmission.

The risk of a person transmitting the virus to a biting mosquito or through blood is highest when the patient is viremic during the first week of illness.

Clinical Signs & 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 may include headache, myalgia, arthritis, conjunctivitis, nausea/vomiting, or maculopapular rash. Clinical laboratory findings can include lymphopenia, thrombocytopenia, elevated creatinine, and elevated hepatic transaminases.

Acute symptoms typically resolve within 7–10 days. 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, older adults (e.g., > 65 years), and persons with underlying medical conditions (e.g., hypertension, diabetes, or cardiovascular disease). Some patients might have relapse of rheumatologic symptoms (e.g., 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.

Diagnosis & Reporting

Chikungunya virus infection 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 of chikungunya virus infection varies based on place of residence, travel history, and exposures. Dengue and chikungunya viruses are transmitted by the same mosquitoes and have similar clinical features. The two 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. It is important to rule out dengue virus infection because proper clinical management of dengue can improve outcome. Click for the WHO dengue clinical management guidelines [PDF – 160 pages].

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

Preliminary diagnosis is based on the patient’s clinical features, places and dates of travel, and activities. Laboratory diagnosis is generally accomplished by testing serum or plasma to detect virus, viral nucleic acid, or virus-specific immunoglobulin M and neutralizing antibodies. Click for more information about diagnostic testing.

Chikungunya virus disease is a nationally notifiable condition. Healthcare providers are encouraged to report suspected chikungunya cases to their state or local health department to facilitate diagnosis and mitigate the risk of local transmission.

Treatment

There is no specific antiviral therapy for chikungunya virus infection. Treatment is for symptoms and can include rest, fluids, and use of non-steroidal anti-inflammatory drugs (NSAIDs) to relieve acute pain and fever. Persistent joint pain may benefit from use of NSAIDs, corticosteroids, or physiotherapy. People infected with chikungunya should be protected from further mosquito exposure during the first week of illness to reduce the risk of local transmission.