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LETTER TO EDITOR  
Year : 2017  |  Volume : 9  |  Issue : 1  |  Page : 33-34
Acute respiratory distress syndrome: An unusual presentation of chikungunya fever viral infection


Department of Pulmonary and Critical Care Medicine, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India

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Date of Web Publication13-Feb-2017
 

How to cite this article:
Singh A. Acute respiratory distress syndrome: An unusual presentation of chikungunya fever viral infection. J Global Infect Dis 2017;9:33-4

How to cite this URL:
Singh A. Acute respiratory distress syndrome: An unusual presentation of chikungunya fever viral infection. J Global Infect Dis [serial online] 2017 [cited 2017 Apr 30];9:33-4. Available from: http://www.jgid.org/text.asp?2017/9/1/33/194374


Sir,

Chikungunya fever is an arthropod-borne viral disease that has been a major global health problem since the last decade.[1] It has diverse clinical manifestations, ranging from asymptomatic infection to atypical or rare infections and complications. Typical systemic clinical manifestations include fever, arthralgia, skin rashes, headache, backache, nausea, vomiting, joint swelling, myalgia, lymphadenopathy, fatigue, and anorexia whereas rare complications include convulsions, meningoencephalitis, fulminant hepatitis, acute renal failure, respiratory failure, and myocarditis.[2],[3] Atypical and complicated features are reported in <0.5% of cases and more frequently observed in elderly patients, pregnancy as well as children, and/or in the presence of underlying diseases such as hypertension, cardiovascular, or respiratory conditions.[2] Respiratory manifestations such as pneumonia and acute respiratory distress syndrome (ARDS) are unusual with chikungunya fever. We are reporting here a case of a patient with chikungunya fever without any comorbid illness who developed acute hypoxemic respiratory failure leading to ARDS.

A 24-year-old previously healthy male was admitted to the hospital with complaints of high-grade fever, arthralgia, backache, headache, and decreased appetite for 8 days followed by breathlessness for 2 days. His vital parameters recorded on examination were pulse - 120/min, blood pressure - 90/60 mm Hg, respiratory rate - 45/min, temperature 103°F, and pulse oximetry 88% on room air. He also had subconjunctival suffusion along with diffuse erythematous macular rash on the face, trunk, and peripheral extremities. Other systemic examination was unremarkable. He was found to have anemia (hemoglobin 6.6 g/dl), leukopenia (3500/cm 3) with relative lymphocytosis, and mild thrombocytopenia (130,000/cm 3) with normal coagulation profile. Chikungunya IgM antibody by ELISA (Xcyton, Bengaluru, India) was detected positive in serum while dengue, leptospirosis, malaria, typhoid fever, meningococcemia, scrub typhus, rickettsia, and other severe bacterial, viral, and parasitic diseases prevalent locally were also ruled out. The patient was also analyzed for serum using ELISA for Japanese encephalitis and other viruses to rule out any evidence of coinfection. Reverse transcriptase polymerase chain reaction for chikungunya virus (Amplisure Chikungunya RT-PCR Kit, RAS Lifesciences Private Limited, Hyderabad, India) in serum was also detected positive for further confirmation. Rest all laboratory investigations including echocardiography were unremarkable. His chest skiagram revealed bilateral infiltrates involving all zones with normal cardiac size with no evidence of consolidation and pleural effusion suggestive of ARDS. The arterial blood gas on room air showed a PaO2 of 51.7 mm Hg, PaCO2 of 25.4 mm Hg, HCO3 of 20.2 mmol, and pH of 7.52 with wide alveolar–arterial gradient 60.3 mm Hg (respiratory alkalosis with metabolic acidosis with hypoxemic respiratory failure). The working diagnosis of mild ARDS as per Berlin criteria [4] secondary to chikungunya infection was established with baseline Acute Physiology and Chronic Health Evaluation score of 14. He was managed with noninvasive ventilation in view of acute hypoxemic respiratory failure. Fluid resuscitation and intravenous acetaminophen were started along with hemodynamic monitoring followed by subsequent resuscitation with vasopressor support. He was given two units of packed red blood cells. His general condition subsequently improved as he became afebrile after 4 days of admission and vasopressor requirement decreased. There was also improvement in gas exchange parameters as there was improvement in PaO2-86.4 mm Hg with normalization of alveolar–arterial gradient to 17.3 mm Hg. Repeat hemoglobin was 9.5 g/dl. The patient was managed conservatively with general supportive measures. The patient was discharged in stable condition on the 10th day after admission.

The association of respiratory failure leading to ARDS with chikungunya fever has been rarely reported with limited evidence.[2],[5],[6],[7] The pathophysiology of chikungunya fever in humans has not been extensively studied.[3],[8] This issue has been addressed because of a rare clinical manifestation of a common disease in a previously normal patient, and it also highlights an important, potentially fatal complication of this disease although the patient has been successfully cured. Chikungunya fever seems to be responsible for atypical or fatal clinical presentations not only in elderly patients or patients at high risk but also in younger patients with an unremarkable medical history.[6] It has been strongly suspected to have neurologic, hepatic, and myocardial tropism, with dramatic complications and mortality.[2],[7] Majority of cases are usually self-limiting with recovery as usual outcome, but there are fatal febrile outbreaks with significant mortality.[8],[9] Therefore, the treatment and outcome of this infection still remains uncertain. There is requirement of immense efforts in creating further development in the field of science, patient care, and public health pertaining to chikungunya fever to limit its current rapid spread and fatal clinical manifestations as well as complications.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
Simon F, Savini H, Parola P. Chikungunya: A paradigm of emergence and globalization of vector-borne diseases. Med Clin North Am 2008;92:1323-43, ix.  Back to cited text no. 1
    
2.
Economopoulou A, Dominguez M, Helynck B, Sissoko D, Wichmann O, Quenel P, et al. Atypical chikungunya virus infections: Clinical manifestations, mortality and risk factors for severe disease during the 2005-2006 outbreak on Réunion. Epidemiol Infect 2009;137:534-41.  Back to cited text no. 2
    
3.
Simon F, Javelle E, Oliver M, Leparc-Goffart I, Marimoutou C. Chikungunya virus infection. Curr Infect Dis Rep 2011;13:218-28.  Back to cited text no. 3
    
4.
ARDS Definition Task Force, Ranieri VM, Rubenfeld GD, Thompson BT, Ferguson ND, Caldwell E, et al. Acute respiratory distress syndrome: The berlin definition. JAMA 2012;307:2526-33.  Back to cited text no. 4
    
5.
Crosby L, Perreau C, Madeux B, Cossic J, Armand C, Herrmann-Storke C, et al. Severe manifestations of chikungunya virus in critically ill patients during the 2013-2014 Caribbean outbreak. Int J Infect Dis 2016;48:78-80.  Back to cited text no. 5
    
6.
Torres JR, Leopoldo Códova G, Castro JS, Rodríguez L, Saravia V, Arvelaez J, et al. Chikungunya fever: Atypical and lethal cases in the Western Hemisphere: A Venezuelan experience. ID Cases 2014;2:6-10.  Back to cited text no. 6
    
7.
Lemant J, Boisson V, Winer A, Thibault L, André H, Tixier F, et al. Serious acute chikungunya virus infection requiring intensive care during the Reunion Island outbreak in 2005-2006. Crit Care Med 2008;36:2536-41.  Back to cited text no. 7
    
8.
Mohan A, Kiran DH, Manohar IC, Kumar DP. Epidemiology, clinical manifestations, and diagnosis of chikungunya fever: Lessons learned from the re-emerging epidemic. Indian J Dermatol 2010;55:54-63.  Back to cited text no. 8
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9.
Mavalankar D, Shastri P, Bandyopadhyay T, Parmar J, Ramani KV. Increased mortality rate associated with chikungunya epidemic, Ahmedabad, India. Emerg Infect Dis 2008;14:412-5.  Back to cited text no. 9
    

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Correspondence Address:
Abhijeet Singh
Department of Pulmonary and Critical Care Medicine, Vardhaman Mahavir Medical College and Safdarjung Hospital, New Delhi - 110 029
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0974-777X.194374

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2008 Journal of Global Infectious Diseases | Published by Wolters Kluwer - Medknow
Online since 10th December, 2008