Severe Sepsis and Septic Shock Associated with Chikungunya Virus Infection, Guadeloupe, 2014

Chikungunya and other viral arthritis

Several viruses cause acute and chronic arthritis. Millions of people suffered from Chikungunya(CHIK) during the recent epidemics/outbreaks in Asia, Africa and the Americas. Almost 20-40 % failed to recover completely and suffered from chronic pain and arthritis sequel. A wide spectrum of clinical phenotypic arthritis was described. Non-specific arthralgias(NSA) and soft tissue pains were predominant although inflammatory arthritis (mostly undifferentiated)(IA-U) was substantial. Specifically, rheumatoid arthritis(RA) and spondyloarthritis(SpA) like disorders were described. The frequency of biomarkers such as rheumatoid factor(RF) was low. Arthritis was mostly non-erosive in population studies. Abnormal immune mechanisms and persistent specific CHIK virus (CHIKV) IgM and IgG antibodies were shown. The etiopathogenetic evidence was divided between intense joint tissue inflammation due to prolonged virus persistence and abnormal autoimmune mechanisms. There was no specific therapy. The symptomatic management was often combined with an empirical use of disease modifying anti rheumatoid drugs and steroids. Substantial research is required to address knowledge gaps and unravel evidence-based medicine.

A case report of discordant Chikungunya manifestations in a married couple: From acute undifferentiated fever to fatal sepsis with purpura fulminans

Chikungunya virus, an alphavirus transmitted by mosquitoes, causes chikungunya fever, a non-fatal febrile illness characterized by severe arthralgia and rash. We are reporting on two Chikungunya cases who recently returned from the Thailand-Cambodia border. The first case involved a man who presented with atypical manifestations, including purpura fulminans and multi-organ failure, ultimately leading to death. Conversely, the subsequent case pertains to the spouse of the deceased, who exhibited typical symptoms.

Characterization of Clinical and Biologic Manifestations of Chikungunya Among Children in an Urban Area, Thailand: A Retrospective Cohort Study

Chikungunya virus (CHIKV), transmitted by Aedes mosquitoes, has reemerged in Southeast Asia since 2019. A retrospective review of CHIKV cases was conducted. Children commonly presented with high-grade fever, rash, arthralgia, and lymphopenia. Neurological manifestations or shock occurred in 20% of hospitalized children. These findings indicate the need for increased vigilance for CHIKV alongside dengue in travelers from Southeast Asia with suspected mosquito-borne viral infections.

Chikungunya: From Hypothesis to Evidence of Increased Severe Disease and Fatalities

Chikungunya virus infection often manifests as an acute, self-limiting febrile illness, with arthralgia and musculoskeletal symptoms being the most commonly reported. Arthralgia can persist for months or even years, and approximately 50% of cases progress to chronic conditions. However, recent outbreaks have revealed a rising number of severe cases and fatalities. This review examines evidence from the past decade that suggests a higher incidence of severe chikungunya virus (CHIKV) infections and increased mortality rates, challenging official reports and guidelines from many countries. The literature review includes case reports, series, and studies with comparison groups to assess whether CHIKV-related mortality is underreported. Evaluating excess mortality involves analyzing consistent findings across different regions, biological plausibility, and systemic manifestations that contribute to severe outcomes. These findings aim to expand disease classifications in international guidelines and raise awareness among healthcare professionals to better identify severe CHIKV cases and related deaths. Studies were identified through PubMed using the search terms "chikungunya", "death", "severe", "pathogenesis", and "pathophysiology".

Cardiac Biomarkers in a Brazilian Indigenous Population Exposed to Arboviruses: A Cross-Sectional Study

Arthropod-borne viral diseases are acute febrile illnesses, sometimes with chronic effects, that can be debilitating and even fatal worldwide, affecting particularly vulnerable populations. Indigenous communities face not only the burden of these acute febrile illnesses, but also the cardiovascular complications that are worsened by urbanization. A cross-sectional study was conducted in an Indigenous population in the Northeast Region of Brazil to explore the association between arboviral infections (dengue, chikungunya, and Zika) and cardiac biomarkers, including cardiotrophin 1, growth differentiation factor 15, lactate dehydrogenase B, fatty-acid-binding protein 3, myoglobin, N-terminal pro-B-type natriuretic peptide, cardiac troponin I, big endothelin 1, and creatine kinase-MB, along with clinical and anthropometric factors. The study included 174 individuals from the Fulni-ô community, with a median age of 47 years (interquartile range 39.0 to 56.0). High rates of previous exposure to dengue, chikungunya, and Zika were observed (92.5%, 78.2%, and 95.4% anti-IgG, respectively), while acute exposure (anti-IgM) remained low. The biomarkers were linked to age (especially in the elderly), obesity, chronic kidney disease, and previous or recent exposure to chikungunya. This study pioneers the use of Luminex xMAP technology to reveal the association between cardiac inflammatory biomarkers and exposure to classical arboviruses in an Indigenous population undergoing urbanization.

Chikungunya infection in children: clinical profile and outcome

The clinical profile and outcomes of children with chikungunya infection differ from those observed in adults. As there is a paucity of data on chikungunya infection in children, this study aimed to find the clinical course, complications, and mortality rates of chikungunya infection in children. This was a combined retrospective and prospective observational study. Children aged 1 month to 15 years who tested positive for chikungunya infection by IgM enzyme-linked immunosorbent assay and reverse transcription polymerase chain reaction in serum or body fluids were included. The demographic details, clinical presentation, laboratory parameters, treatment given, and outcomes were recorded in a structured proforma. Fifty-eight cases (41 retrospective and 17 prospective) were recruited, out of which 30 (52%) were males. The median age was 8 (3-11) years. The most common clinical feature at admission was fever observed in 55 patients (94.8%), followed by vomiting [25 (43.1%)] and myalgia [23 (39.7%)]. Commonly observed clinical signs were skin rash [32 (55.2%)], hepatomegaly [25 (43.1%)], and anemia [22 (37.9%)]. Frequently observed acute complications were lymphopenia [46 (79.3%)], hyponatremia [32 (55.2%)], capillary leak [27 (46.6%)], and thrombocytopenia [26 (44.8%)]. Of 58 cases, 8 (13.8%) children had co-infection with other microbes. Overall, 55 (94.8%) children had complete recovery, 2 (3.4%) children died of complications (one with acute encephalitis and one child with acute respiratory distress syndrome), and 5 children had prolonged arthralgia. Children with chikungunya had more skin manifestations and neurological manifestations than arthralgia. Also, a significant proportion of children developed serious complications like a capillary leak.

Pathophysiology of chikungunya virus infection associated with fatal outcomes

Chikungunya virus (CHIKV) is a mosquito-borne alphavirus that causes acute, subacute, and chronic human arthritogenic diseases and, in rare instances, can lead to neurological complications and death. Here, we combined epidemiological, virological, histopathological, cytokine, molecular dynamics, metabolomic, proteomic, and genomic analyses to investigate viral and host factors that contribute to chikungunya-associated (CHIK) death. Our results indicate that CHIK deaths are associated with multi-organ infection, central nervous system damage, and elevated serum levels of pro-inflammatory cytokines and chemokines compared with survivors. The histopathologic, metabolite, and proteomic signatures of CHIK deaths reveal hemodynamic disorders and dysregulated immune responses. The CHIKV East-Central-South-African lineage infecting our study population causes both fatal and survival cases. Additionally, CHIKV infection impairs the integrity of the blood-brain barrier, as evidenced by an increase in permeability and altered tight junction protein expression. Overall, our findings improve the understanding of CHIK pathophysiology and the causes of fatal infections.

Chikungunya: a decade of burden in the Americas

In the Americas, one decade following its emergence in 2013, chikungunya virus (CHIKV) continues to spread and cause epidemics across the region. To date, 3.7 million suspected and laboratory-confirmed chikungunya cases have been reported in 50 countries or territories in the Americas. Here, we outline the current status and epidemiological aspects of chikungunya in the Americas and discuss prospects for future research and public health strategies to combat CHIKV in the region.

The relationship between chikungunya virus and the kidneys: A scoping review

Several atypical forms of chikungunya fever (CHIK) have been described, including neurological, cardiac and renal involvement. These forms may be related to high morbidity and mortality rates. This scoping review based on the PubMed, Scopus, and WOS databases aims to identify and summarise all the available evidence regarding the clinical and histopathological presentations and risk factors associated with kidney injury related to CHIK, as well as the clinical impact. Thus, a total of 54 papers were selected from 1606 initial references after applying the defined inclusion criteria. Data on the association between kidney injury and CHIK are scarce, with studies only conducted in the acute phase of the disease, lacking further characterisation. Kidney injury incidence in hospitalised patients using the Kidney Disease Improving Global Outcomes criteria varies from 21% to 45%, being higher among patients with atypical and severe manifestations. Although acute kidney injury does not seem to be related to viraemia, it may be related to higher mortality. Few studies have described the renal histopathological changes in the acute phase of CHIK, with prevalent findings of acute interstitial nephritis with mononuclear infiltrate, glomerular congestion and nephrosclerosis. Only one study assessed the kidney function of patients in the subacute and chronic phases of CHIK. Additionally, individuals with comorbidities, including chronic kidney disease, may be among those with a greater risk of presenting worse outcomes when affected by CHIK. The results described herein may contribute to better understand the relationship between the kidneys and chikungunya virus.

Heart Disease and Arboviruses: A Systematic Review and Meta-Analysis

Dengue fever, chikungunya, and zika are highly prevalent arboviruses transmitted by hematophagous arthropods, with a widely neglected impact in developing countries. These diseases cause acute illness in diverse populations, as well as potential cardiovascular complications. A systematic review was carried out to investigate the burden of cardiac involvement related to these arboviruses. Multiple databases were searched for articles that investigated the association of cardiovascular diseases with arboviruses, published up to March 2022. Relevant articles were selected and rated by two independent reviewers. Proportion meta-analysis was applied to assess the frequency-weighted mean of the cardiovascular findings. A total of 42 articles were selected (n = 76,678 individuals), with 17 manuscripts on dengue and 6 manuscripts on chikungunya undergoing meta-analysis. The global pooled incidence of cardiac events in dengue fever using a meta-analysis was 27.21% (95% CI 20.21–34.83; I² = 94%). The higher incidence of dengue-related myocarditis was found in the population younger than 20 years old (33.85%; 95% CI 0.00–89.20; I² = 99%). Considering the studies on chikungunya (n = 372), the global pooled incidence of cardiac involvement using a meta-analysis was 32.81% (95% CI 09.58–61.49, I² = 96%). Two Zika studies were included that examined cases of infection by vertical transmission in Brazil, finding everything from structural changes to changes in heart rate variability that increase the risk of sudden death. In conclusion, cardiac involvement in arboviruses is not uncommon, especially in dengue fever.

Atypical skin manifestation in severe acute chikungunya infection in a pregnant woman: a case report

INTRODUCTION

Patients with chikungunya virus infection commonly present with fever, skin rash, and severe joint pain. The vesiculobullous rash is rare in adults but common in infants. In addition, septic shock and acute respiratory distress syndrome are rare complications of atypical and severe acute chikungunya infection.

CASE PRESENTATION

We report the presence of an 18-year-old Thai female, at 31 weeks gestation, with fever, maculopapular rash, and polyarthritis. The rash later progressed to a vesiculobullous pattern, and she developed septic shock and acute respiratory distress syndrome. Skin biopsy and blood were positive for chikungunya virus RNA. The patient was intubated with a mechanical ventilator and subsequently fully recovered.

CONCLUSION

Atypical skin manifestation and severe acute disease is likely due to immune response attenuation in pregnancy. The possibility of progression to severe or atypical disease in pregnant women suffering chikungunya should always be considered.

The global burden of Chikungunya fever among children: A systematic literature review and meta-analysis

Chikungunya fever (CHIKF) is an arboviral illness that was first described in Tanzania (1952). In adults, the disease is characterised by debilitating arthralgia and arthritis that can persist for months, with severe illness including neurological complications observed in the elderly. However, the burden, distribution and clinical features of CHIKF in children are poorly described. We conducted a systematic literature review and meta-analysis to determine the epidemiology of CHIKF in children globally by describing its prevalence, geographical distribution, and clinical manifestations. We searched electronic databases for studies describing the epidemiology of CHIKF in children. We included peer-reviewed primary studies that reported laboratory confirmed CHIKF. We extracted information on study details, sampling approach, study participants, CHIKF positivity, clinical presentation and outcomes of CHIKF in children. The quality of included studies was assessed using Joanna Briggs Institute Critical Appraisal tool for case reports and National Institute of Health quality assessment tool for quantitative studies and case series. Random-effects meta-analysis was used to estimate the pooled prevalence of CHIKF among children by geographical location. We summarised clinical manifestations, laboratory findings, administered treatment and disease outcomes associated with CHIKF in children. We identified 2104 studies, of which 142 and 53 articles that met the inclusion criteria were included in the systematic literature review and meta-analysis, respectively. Most of the selected studies were from Asia (54/142 studies) and the fewest from Europe (5/142 studies). Included studies were commonly conducted during an epidemic season (41.5%) than non-epidemic season (5.1%). Thrombocytopenia was common among infected children and CHIKF severity was more prevalent in children <1 year. Children with undifferentiated fever before CHIKF was diagnosed were treated with antibiotics and/or drugs that managed specific symptoms or provided supportive care. CHIKF is a significant under-recognised and underreported health problem among children globally and development of drugs/vaccines should target young children.

The MAVS Immune Recognition Pathway in Viral Infection and Sepsis

Significance: It is estimated that close to 50 million cases of sepsis result in over 11 million annual fatalities worldwide. The pathognomonic feature of sepsis is a dysregulated inflammatory response arising from viral, bacterial, or fungal infections. Immune recognition of pathogen-associated molecular patterns is a hallmark of the host immune defense to combat microbes and to prevent the progression to sepsis. Mitochondrial antiviral signaling protein (MAVS) is a ubiquitous adaptor protein located at the outer mitochondrial membrane, which is activated by the cytosolic pattern recognition receptors, retinoic acid-inducible gene I (RIG-I) and melanoma differentiation associated gene 5 (MDA5), following binding of viral RNA agonists. Recent Advances: Substantial progress has been made in deciphering the activation of the MAVS pathway with its interacting proteins, downstream signaling events (interferon [IFN] regulatory factors, nuclear factor kappa B), and context-dependent type I/III IFN response. Critical Issues: In the evolutionary race between pathogens and the host, viruses have developed immune evasion strategies for cleavage, degradation, or blockade of proteins in the MAVS pathway. For example, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) M protein and ORF9b protein antagonize MAVS signaling and a protective type I IFN response. Future Directions: The role of MAVS as a sensor for nonviral pathogens, host cell injury, and metabolic perturbations awaits better characterization in the future. New technical advances in multidimensional single-cell analysis and single-molecule methods will accelerate the rate of new discoveries. The ultimate goal is to manipulate MAVS activities in the form of immune-modulatory therapies to combat infections and sepsis. Antioxid. Redox Signal. 35, 1376-1392.

Clinical Features of Acute Chikungunya Virus Infection in Children and Adults during an Outbreak in the Maldives

The chikungunya virus is an arthritogenic arbovirus that has re-emerged in many tropical and subtropical regions, causing explosive outbreaks. This re-emergence is due to a genomic polymorphism that has increased the vector susceptibility of the virus. The majority of those infected with chikungunya virus exhibit symptoms of fever, rash, and debilitating polyarthralgia or arthritis. Symptoms can persist for weeks, and patients can relapse months later. Fatalities are rare, but individuals of extreme age can develop severe infection. Here, we describe the 2019 outbreak, the second-largest since the virus re-emerged in the Maldives after the 2004 Indian Ocean epidemic, in which a total of 1,470 cases were reported to the Health Ministry. Sixty-seven patients presenting at the main referral tertiary care hospital in the Maldives capital with acute undifferentiated illness were recruited following a negative dengue serology. A novel point-of-care antigen kit was used to screen suspected cases, 50 of which were subsequently confirmed using real-time reverse transcription-polymerase chain reaction. We describe the genotype and polymorphism of Maldives chikungunya virus using phylogenetic analysis. All isolates were consistent with the East Central South African genotype of the Indian Ocean lineage, with a specific E1-K211E mutation. In addition, we explored the clinical and laboratory manifestations of acute chikungunya in children and adults, of which severe infection was found in some children, whereas arthritis primarily occurred in adults. Arthritides in adults occurred irrespective of underlying comorbidities and were associated with the degree of viremia.

Clinical Characteristics, Histopathology, and Tissue Immunolocalization of Chikungunya Virus Antigen in Fatal Cases

BACKGROUND

Death in patients with chikungunya is rare and has been associated with encephalitis, hemorrhage, and septic shock. We describe clinical, histologic, and immunohistochemical findings in individuals who died following chikungunya virus (CHIKV) infection.

METHODS

We identified individuals who died in Puerto Rico during 2014 following an acute illness and had CHIKV RNA detected by reverse transcriptase-polymerase chain reaction in a pre- or postmortem blood or tissue specimen. We performed histopathology and immunohistochemistry (IHC) for CHIKV antigen on tissue specimens and collected medical data via record review and family interviews.

RESULTS

Thirty CHIKV-infected fatal cases were identified (0.8/100 000 population). The median age was 61 years (range: 6 days-86 years), and 19 (63%) were male. Death occurred a median of 4 days (range: 1-29) after illness onset. Nearly all (93%) had at least 1 comorbidity, most frequently hypertension, diabetes, or obesity. Nine had severe comorbidities (eg, chronic heart or kidney disease, sickle cell anemia) or coinfection (eg, leptospirosis). Among 24 fatal cases with tissue specimens, 11 (46%) were positive by IHC. CHIKV antigen was most frequently detected in mesenchymal tissues and mononuclear cells including tissue macrophages, blood mononuclear cells, splenic follicular dendritic cells, and Kupffer cells. Common histopathologic findings were intra-alveolar hemorrhage and edema in the lung, chronic or acute tenosynovitis, and increased immunoblasts in the spleen. CHIKV infection likely caused fatal septic shock in 2 patients.

CONCLUSIONS

Evaluation of tissue specimens provided insights into the pathogenesis of CHIKV, which may rarely result in septic shock and other severe manifestations.

Rediscovering the chikungunya virus

El virus de chikunguña (CHIKV) es un Alfavirus perteneciente al grupo denominado del Viejo Mundo; estos son virus artritogénicos que causan una enfermedad febril caracterizada por artralgias y mialgias. Aunque la muerte por CHIKV es poco frecuente, la enfermedad puede llegar a ser incapacitante y generar un amplio espectro de manifestaciones atípicas, como complicaciones cardiovasculares, respiratorias, oculares, renales y dérmicas, entre otras. Cuando el dolor articular persiste por tres o más meses, da lugar a la forma crónica de la enfermedad denominada reumatismo inflamatorio crónico poschikunguña, el cual es la principal secuela de la enfermedad. Se considera que este virus no es neurotrópico, sin embargo, puede afectar el sistema nervioso central y generar secuelas graves y permanentes, principalmente, en niños y ancianos.

En África, Asia y Europa se habían reportado anteriormente brotes epidémicos por CHIKV, pero solo hasta finales del 2013 se documentó la introducción del virus a las Américas; desde entonces, el virus se ha propagado a 45 países o territorios del continente y el número de casos acumulados ascendió a cerca de dos millones en dos años.

Esta revisión describe de manera general la biología molecular del virus, sus manifestaciones clínicas, su patogénesis y las principales complicaciones posteriores a la infección. Además, reúne la información de la epidemia en Colombia y el continente americano publicada entre el 2014 y el 2020.

Contribution of Research in the West Indies and Northeast Amazonia to Knowledge of the 2014-2015 Chikungunya Epidemic in the Americas

Purpose of Review

Although the chikungunya virus was discovered more than 60 years ago, it has only really been studied since the outbreak in La Reunion in 2005-2006. Ten years later, between 2014 and 2015, the chikungunya virus spread throughout the Americas, affecting millions of people. The objective of this review is to describe the contributions of research on chikungunya virus infection gained from epidemic in the West Indies and the Guiana Shield.

Recent Findings

Prevalence data were similar to those found in the Indian Ocean or Asia during epidemics. Clinically, there is now a better understanding of the typical, atypical, and severe forms. Several studies have insisted on the presence of neurological forms of chikungunya infection, such as encephalitis or Guillain-Barré syndrome. Cases of septic shock due to chikungunya virus as well as thrombotic thrombocytopenic purpura were described for the first time. Given the magnitude of the epidemic and the large number of people affected, this has led to a better description and new classifications of chikungunya virus infections in specific populations such as pregnant women, the elderly, and children. Several studies also described the behavior of populations faced with an emerging disease.

Summary

Current epidemiological data from tropical regions highlights the risk of spreading emerging diseases at higher latitudes, especially concerning arboviruses, since the vector Aedes albopictus is already established in many parts of northern countries. A better understanding of the disease and its epidemic dynamics will foster better management, the crucial importance of which was demonstrated during the COVID-19 epidemic.

Vertical transmission of chikungunya virus: A systematic review

Objectives

To describe and estimate the frequency of pregnancy outcomes, clinical and laboratory characteristics of vertical transmission of CHIKV in the neonate.

Study design

We performed a systematic review evaluating the clinical presentation of perinatally-acquired CHIKV infection in neonates. The search was performed using Medline (via PubMed), LILACS, Web of Science, Scielo, Google Scholar and Open grey to identify studies assessing vertical transmission of CHIKV up to November 3, 2020. There were no search restrictions regarding the study type, the publication date or language. Studies with no documented evidence of CHIKV infection in neonates (negative RT-PCR or absence of IgM) were excluded.

Results

From the 227 studies initially identified, 42 were selected as follows: 28 case reports, 7 case series, 2 cross-sectional studies and 5 cohort studies, for a total of 266 CHIKV infected neonates confirmed by serological and/or molecular tests. The vertical transmission rate was 50% in the Reunion Island outbreak, which was the subject of the majority of the studies; the premature delivery were reported in 19 (45.2%) studies; the rate of fetal distress was 19.6% of infected babies and fetal loss occurred in 2% of the cases. Approximately 68.7% of newborns were diagnosed with encephalopathy or encephalitis after perinatally acquired CHIKV. Most of the infected neonates were born healthy, developing CHIKV sepsis clinical syndrome within the first week of life.

Conclusions

We alert neonatologists to the late manifestations of neonatal CHIKV infection, relevant to the management and reduction of morbidity. A limitation of our review was that it was not possible to carry out meta-analysis due to differences in study design and the small number of participants.

Nanotechnological strategies for systemic microbial infections treatment: A review

Systemic infections is one of the major causes of mortality worldwide, and a shortage of drug approaches applied for the rapid and necessary treatment contribute to increase the levels of death in affected patients. Several drug delivery systems based in nanotechnology such as metallic nanoparticles, liposomes, nanoemulsion, microemulsion, polymeric nanoparticles, solid lipid nanoparticles, dendrimers, hydrogels and liquid crystals can contribute in the biological performance of active substances for the treatment of microbial diseases triggered by fungi, bacteria, virus and parasites. In the presentation of these statements, this review article present and demonstrate the effectiveness of these drug delivery systems for the treatment of systemic diseases caused by several microorganisms, through a review of studies on scientific literature worldwide that contributes to better information for the most diverse professionals from the areas of health sciences. The studies demonstrated that the drug delivery systems described can contribute to the therapeutic scenario of these diseases, being classified as safe, active platforms and with therapeutic versatility.

Respiratory viral sepsis: epidemiology, pathophysiology, diagnosis and treatment

According to the Third International Consensus Definition for Sepsis and Septic Shock, sepsis is a life-threatening organ dysfunction resulting from dysregulated host responses to infection. Epidemiological data about sepsis from the 2017 Global Burden of Diseases, Injuries and Risk Factor Study showed that the global burden of sepsis was greater than previously estimated. Bacteria have been shown to be the predominant pathogen of sepsis among patients with pathogens detected, while sepsis caused by viruses is underdiagnosed worldwide. The coronavirus disease that emerged in 2019 in China and now in many other countries has brought viral sepsis back into the vision of physicians and researchers worldwide. Although the current understanding of the pathophysiology of sepsis has improved, the differences between viral and bacterial sepsis at the level of pathophysiology are not well understood. Diagnosis methods that can broadly differentiate between bacterial and viral sepsis at the initial stage after the development of sepsis are limited. New treatments that can be applied at clinics for sepsis are scarce and this situation is not consistent with the growing understanding of pathophysiology. This review aims to give a brief summary of current knowledge of the epidemiology, pathophysiology, diagnosis and treatment of viral sepsis.

Chikungunya in a kidney transplant recipient: a case report

In 2004, a global spread of Chikungunya fever affected most tropical and subtropical regions of the world. In 2016, an outbreak occurred in Northeast Brazil with hundreds of cases documented. Solid organ transplant recipients have a modified immune response to infection and the clinical course is usually different from immunocompetent patients. The diagnosis can be challenging in this population. Most reports describe patients residing in endemic areas, although we must emphasize the importance of differential diagnosis in kidney transplanted travelers who visit endemic regions, such as Northeast Brazil. Here, we reported a case of a kidney transplant recipient that acquired Chikungunya fever after a trip to an endemic region at Northeast Brazil during the outbreak in 2016, with a good clinical evolution. We also present warning recommendations for travelers to endemic areas as additional measures to prevent disease outbreaks.

Events preceding death among chikungunya virus infected patients: a systematic review

Since its re-emergence in the late 1990s, there have been reports of Chikungunya fever (CHIK-F) presenting with severe or atypical findings. There is little knowledge regarding the clinical events leading to the death of patients with CHIK-F. This study aimed to systematically review the literature regarding CHIK-F and identify clinical features preceding death. We searched PubMed, Scopus, Embase, Lilacs, and IsiWeb for case-reports, case-series, or cohorts of CHIK-F reporting at least one death, up to December 2019. Fifty-seven reports were analyzed, including 2140 deaths. Data about specific clinical events that precede death are scarce. The central tendency of time between disease onset and death ranged from 2 days to 150 days. The most common clinical findings among decedents were fever (22.0%), arthralgia (15.7%), myalgia (10.7%), and headache (8.2%). Excluding pediatric populations, the reported central tendency of age among the decedents was 53 or older, with a non-weighted median of 67, ranging up to 80 years old. Authors mentioned organic dysfunction in 91.2% reports. Among all the 2140 decedents, the most common dysfunctions were cardiovascular (7.2%), respiratory (6.4%), neurological (5.4%), renal (4.2%), liver (3.0%), and hematological (1.3%) dysfunction. Exacerbation of previous diabetes (5.6%) or hypertension (6.9%) was mentioned as conditions preceding death. Currently, older age, primary neurological, cardiovascular, or respiratory dysfunction and a previous diagnosis of diabetes or hypertension are the main clinical events preceding death.

Epidemiology of Dengue, Chikungunya, and Zika Virus Disease in U.S. States and Territories, 2017

Dengue, chikungunya, and Zika viruses, primarily transmitted by Aedes species mosquitoes, have caused large outbreaks in the Americas, leading to travel-associated cases and local mosquito-borne transmission in the United States. We describe the epidemiology of dengue, chikungunya, and noncongenital Zika virus disease cases reported from U.S. states and territories in 2017, including 971 dengue cases, 195 chikungunya cases, and 1,118 Zika virus disease cases. Cases of all three diseases reported from the territories were reported as resulting from local mosquito-borne transmission. Cases reported from the states were primarily among travelers, with only seven locally acquired mosquito-transmitted Zika virus disease cases reported from Texas (n = 5) and Florida (n = 2). In the territories, most dengue cases (n = 508, 98%) were reported from American Samoa, whereas the majority of chikungunya (n = 39, 100%) and Zika virus disease (n = 620, 93%) cases were reported from Puerto Rico. Temporally, the highest number of Zika virus disease cases occurred at the beginning of the year, followed by a sharp decline, mirroring decreasing case numbers across the Americas following large outbreaks in 2015 and 2016. Dengue and chikungunya cases followed a more seasonal pattern, with higher case numbers from July through September. Travelers to the United States and residents of areas with active virus transmission should be informed of both the ongoing risk from dengue, chikungunya, and Zika virus disease and personal protective measures to lower their risk of mosquito bites and to help prevent the spread of these diseases.

Granzyme A in Chikungunya and Other Arboviral Infections

Granzyme A (GzmA) is secreted by cytotoxic lymphocytes and has traditionally been viewed as a mediator of cell death. However, a growing body of data suggests the physiological role of GzmA is promotion of inflammation. Here, we show that GzmA is significantly elevated in the sera of chikungunya virus (CHIKV) patients and that GzmA levels correlated with viral loads and disease scores in these patients. Serum GzmA levels were also elevated in CHIKV mouse models, with NK cells the likely source. Infection of mice deficient in type I interferon responses with CHIKV, Zika virus, or dengue virus resulted in high levels of circulating GzmA. We also show that subcutaneous injection of enzymically active recombinant mouse GzmA was able to mediate inflammation, both locally at the injection site as well as at a distant site. Protease activated receptors (PARs) may represent targets for GzmA, and we show that treatment with PAR antagonist ameliorated GzmA- and CHIKV-mediated inflammation.

Chikungunya disease among infants in French West Indies during the 2014 outbreak

BACKGROUND

We aimed to describe the clinical and laboratory features of Chikungunya disease in infants aged from 1 month to 2years.

METHODS

This epidemiologic study was carried out at the Pointe-à-Pitre University Hospital from May to September 2014. We collected data prospectively from infants hospitalized for Chikungunya disease.

RESULTS

A total of 154 infants were included. Hyperthermia was greater than 38.5°C the first 48h and during on average 2.7 days. Pain (on mobilization and/or cutaneous hyperesthesia and/or arthralgia) was present in 82% of the cases. Loss of appetite was reported for 62% of the infants. Initial maculopapular erythematous eruption occurred in 69% of the cases. A vesiculobullous eruption was secondarily observed in 7% of the cases. Edema on the feet and/or hands was present in 48% of the cases. Febrile seizure was observed in 12% of the cases. Lymphopenia was the most frequent laboratory finding, present in 94% of the infants. No cases of thrombocytopenia were observed. The reported complications were: bullous epidermolysis, state of epilepticus, and severe acute hepatitis.

CONCLUSION

This study highlights a suggestive clinical presentation of Chikungunya diseases combining pain, fever, tachycardia, foot and/or hand edema. Lymphopenia, monocytosis, and the absence of thrombocytopenia were relevant biological signs.

Systems analysis of subjects acutely infected with the Chikungunya virus

The largest ever recorded epidemic of the Chikungunya virus (CHIKV) broke out in 2004 and affected four continents. Acute symptomatic infections are typically associated with the onset of fever and often debilitating polyarthralgia/polyarthritis. In this study, a systems biology approach was adopted to analyze the blood transcriptomes of adults acutely infected with the CHIKV. Gene signatures that were associated with viral RNA levels and the onset of symptoms were identified. Among these genes, the putative role of the Eukaryotic Initiation Factor (eIF) family genes and apolipoprotein B mRNA editing catalytic polypeptide-like (APOBEC3A) in the CHIKV replication process were displayed. We further compared these signatures with signatures induced by the Dengue virus infection and rheumatoid arthritis. Finally, we demonstrated that the CHIKV in vitro infection of murine bone marrow-derived macrophages induced IL-1 beta production in a mechanism that is significantly dependent on the inflammasome NLRP3 activation. The observations provided valuable insights into virus-host interactions during the acute phase and can be instrumental in the investigation of new and effective therapeutic interventions.

The Chikungunya virus (CHIKV) has infected millions of people worldwide and presents a serious public health issue. Acute symptomatic infections caused by contracting this mosquito-transmitted arbovirus are typically associated with an abrupt onset of fever and often debilitating polyarthralgia/ polyarthritis, as well as prolonged periods of disability in some patients. These dramatic effects call for a careful evaluation of the molecular mechanisms involved in this puzzling infection. By analyzing the blood transcriptome of adults acutely infected with CHIKV, we were able to provide a detailed picture of the early molecular events induced by the infection. Additionally, the systems biology approach revealed genes that can be investigated extensively as probable therapeutic targets for the disease.

Severe chikungunya requiring intensive care in two travellers returning to the UK

Chikungunya (CHIKV), an Alphavirus transmitted by Aedes mosquitoes, has been responsible for several outbreaks of infection in Asia and the Americas. Although the severe manifestations of CHIKV are increasingly reported in endemic settings, information on returning travelers is limited. We report two cases of travel-associated acute CHIKV requiring intensive care.

Severe Manifestations of Chikungunya Fever in Children, India, 2016

Chikungunya is a relatively benign disease, and a paucity of literature on severe manifestations in children exits. We describe a cohort of pediatric chikungunya fever patients in New Delhi, India, who had severe sepsis and septic shock, which can develop during the acute phase of illness.

Chikungunya virus infection in Indonesia: a systematic review and evolutionary analysis

Background

Despite the high number of chikungunya cases in Indonesia in recent years, comprehensive epidemiological data are lacking. The systematic review was undertaken to provide data on incidence, the seroprevalence of anti-Chikungunya virus (CHIKV) IgM and IgG antibodies, mortality, the genotypes of circulating CHIKV and travel-related cases of chikungunya in the country. In addition, a phylogenetic and evolutionary analysis of Indonesian CHIKV was conducted.

Methods

A systematic review was conducted to identify eligible studies from EMBASE, MEDLINE, PubMed and Web of Science as of October 16th 2017. Studies describing the incidence, seroprevalence of IgM and IgG, mortality, genotypes and travel-associated chikungunya were systematically reviewed. The maximum likelihood phylogenetic and evolutionary rate was estimated using Randomized Axelerated Maximum Likelihood (RAxML), and the Bayesian Markov chain Monte Carlo (MCMC) method identified the Time to Most Recent Common Ancestors (TMRCA) of Indonesian CHIKV. The systematic review was registered in the PROSPERO database (CRD42017078205).

Results

Chikungunya incidence ranged between 0.16-36.2 cases per 100,000 person-year. Overall, the median seroprevalence of anti-CHIKV IgM antibodies in both outbreak and non-outbreak scenarios was 13.3% (17.7 and 7.3% for outbreak and non-outbreak events, respectively). The median seroprevalence of IgG antibodies in both outbreak and non-outbreak settings was 18.5% (range 0.0–73.1%). There were 130 Indonesian CHIKV sequences available, of which 120 (92.3%) were of the Asian genotype and 10 (7.7%) belonged to the East/Central/South African (ECSA) genotype. The ECSA genotype was first isolated in Indonesia in 2008 and was continually sampled until 2011. All ECSA viruses sampled in Indonesia appear to be closely related to viruses that caused massive outbreaks in Southeast Asia countries during the same period. Massive nationwide chikungunya outbreaks in Indonesia were reported during 2009–2010 with a total of 137,655 cases. Our spatio-temporal, phylogenetic and evolutionary data suggest that these outbreaks were likely associated with the introduction of the ECSA genotype of CHIKV to Indonesia.

Conclusions

Although no deaths have been recorded, the seroprevalence of anti-CHIKV IgM and IgG in the Indonesian population have been relatively high in recent years following re-emergence in early 2001. There is sufficient evidence to suggest that the introduction of ECSA into Indonesia was likely associated with massive chikungunya outbreaks during 2009–2010.

Electronic supplementary material

The online version of this article (10.1186/s12879-019-3857-y) contains supplementary material, which is available to authorized users.

Intensive Care Admissions for Severe Chikungunya Virus Infection, French Polynesia

During the 2014–2015 chikungunya outbreak in French Polynesia, 64 patients with confirmed chikungunya virus infection were admitted into intensive care. Sixty-three were nonpregnant adults; 11 had an atypical form, 21 had severe sepsis or septic shock, and 18 died. These findings indicate that critical illness frequently complicates the course of chikungunya virus infection.

Excess deaths associated with the 2014 chikungunya epidemic in Jamaica

Although traditionally chikungunya virus is considered non-fatal, recent studies suggest that there may be in fact underreporting of deaths in some situations. A major chikungunya epidemic hit Jamaica in 2014 but no chikungunya-associated deaths were reported. We assessed the excess of all-cause deaths during this epidemic. Excess deaths were estimated by difference between observed and expected mortality based on the average age-specific mortality rate of 2012-2013, using the 99% confidence interval. There was an excess of 2,499 deaths during the epidemic (91.9/100,000 population), and a strong positive correlation between the monthly incidence of chikungunya and the excess of deaths (Rho = 0.939, p < 0.005). No significant concomitant epidemiological or climatic phenomenon occurred. Chikungunya is a major contributor to morbidity during epidemics and may be an unrecognized cause of death. Thus, it is urgent to review clinical protocols and improve the investigations of specific-cause deaths during chikungunya epidemics. Excess deaths could be a strategic tool for epidemiological surveillance.

Long-term survival and clinical forms in the acute phase of Chikungunya virus infection in older Caribbeans

OBJECTIVE

To investigate whether the long-term survival in elderly patients with prior Chikungunya virus infection (CVI) is associated with the clinical form presented in the acute phase, as defined by the WHO classification.

METHODS

Retrospective cohort study performed in Martinique University Hospitals. Patients who attended the emergency department for suspected CVI, and who had a positive biological diagnosis of CVI by reverse transcription-polymerase chain reaction on a plasma sample between 10 January and 31 December 2014 were eligible for inclusion. Time-to-death was the primary outcome. The independent relationship between clinical forms and time-to-death was analysed using a Cox model.

RESULTS

In total, 268 patients were included. Mean age was 80 ± 8 years, 53% were women. Median length of follow-up was 28 months (range: 0-39). During follow-up, 53 (19.8%) patients died. Median survival time was 13.2 months (range: 0-33.6). At the end of follow-up, death rates were 4.6% for acute clinical cases, 19.0% for atypical cases, 19.2% for severe acute cases and 23.5% for unclassifiable cases. By multivariable analysis, the clinical form of CVI at admission was found to be independently associated with long-term survival (atypical form: HR = 2.38; 95% CI = 2.15-2.62; severe acute form: HR = 2.40; 95% CI = 2.17-2.64; unclassifiable form: HR = 2.28; 95% CI = 2.06-2.51).

CONCLUSION

The clinical form at presentation with CVI has a significant impact on long-term survival. Management of CVI patients should be tailored according to their clinical form at admission.

Risk factors for hospitalization of patients with chikungunya virus infection at sentinel hospitals in Puerto Rico

Background

Hospitalization of patients during outbreaks of chikungunya virus has been reported to be uncommon (0.5–8.7%), but more frequent among infants and the elderly. CHIKV was first detected in Puerto Rico in May 2014. We enrolled patients with acute febrile illness (AFI) presenting to two hospital emergency departments in Puerto Rico and tested them for CHIKV infection to describe the frequency of detection of CHIKV-infected patients, identify risk factors for hospitalization, and describe patients with severe manifestations.

Methodology/Principal findings

Serum specimens were collected from patients with AFI and tested by rRT-PCR. During May–December 2014, a total of 3,035 patients were enrolled, and 1,469 (48.4%) had CHIKV infection. A total of 157 (10.7%) CHIKV-infected patients were hospitalized, six (0.4%) were admitted to the intensive care unit, and two died (0.1%). Common symptoms among all CHIKV-infected patients were arthralgia (82.6%), lethargy (80.6%), and myalgia (80.5%). Compared to patients aged 1–69 years (7.3%), infant (67.2%) and elderly (17.3%) patients were nine and two times more likely to be hospitalized, respectively (relative risk [RR] and 95% confidence interval [CI] = 9.16 [7.05–11.90] and 2.36 [1.54–3.62]). Multiple symptoms of AFI were associated with decreased risk of hospitalization, including arthralgia (RR = 0.31 [0.23–0.41]) and myalgia (RR = 0.29 [0.22–0.39]). Respiratory symptoms were associated with increased risk of hospitalization, including rhinorrhea (RR = 1.68 [1.24–2.27) and cough (RR = 1.77 [1.31–2.39]). Manifestations present among <5% of patients but associated with patient hospitalization included cyanosis (RR = 2.20 [1.17–4.12) and seizures (RR = 3.23 [1.80–5.81).

Discussion

Among this cohort of CHIKV-infected patients, hospitalization was uncommon, admission to the ICU was infrequent, and death was rare. Risk of hospitalization was higher in patients with symptoms of respiratory illness and other manifestations that may not have been the result of CHIKV infection.

Chikungunya is an emerging infectious disease caused by a virus (chikungunya virus, CHIKV) transmitted through the bite of infected mosquitos; typical symptoms are fever and joint pain. After CHIKV was first detected in Puerto Rico in 2014, an epidemic quickly spread across the island. Because previous reports identified varying frequencies of hospitalization of CHIKV-infected patients, we used an existing hospital-based disease detection system to better understand the frequency and reasons for hospitalization of CHIKV-infected patients in Puerto Rico. Among 1,469 patients with laboratory-confirmed CHIKV infection, 11% were hospitalized, most of whom were infants or elderly. Six CHIKV-infected patients were admitted to the intensive care unit, and two died. Although several illness characteristics were associated with hospitalization, most of these were not typical of chikungunya and instead suggested underlying or concomitant respiratory disease. By enrolling patients when they presented to the emergency department and testing them for evidence of CHIKV infection, we determined that hospitalization in this population occurred in roughly one-in-ten CHIKV-infected patients, one-in-two hundred were admitted to the intensive care unit, and one-in-one thousand died. These findings provide information on the spectrum of disease caused by CHIKV, and identified underlying or concomitant respiratory illness as a risk factor associated with hospitalization.

Atypical and severe manifestations of chikungunya virus infection in French Guiana: A hospital-based study

BACKGROUND

French Guiana (FG) was the first country in South America to declare chikungunya virus infection (CHIKV). The outbreak affected about 16,000 persons between February 2014 and October 2015, with several atypical cases, but only two fatal cases. We aimed to describe the clinical presentation of patients hospitalized for CHIKV infection, to estimate and identify risk factors of unusual and severe forms in adult patients.

MATERIALS AND METHODS

A monocentric retrospective study was conducted in Cayenne hospital, the main city and the main hospital in FG, from March 1st 2014 to August 31st 2015. All patients admitted for at least one night with a biological diagnosis of CHIKV infection during the 2014/2015 outbreak were included, except pregnant women and children under 15 years.

RESULTS

During the study period, 285 patients with a diagnosis of CHIKV infection were hospitalized in Cayenne hospital, among whom 96 nonpregnant adults were studied. Five were classified as severe forms (5.2%) and 23 as unusual forms (23.9%). The most frequent atypical and/or severe form was neurological (n = 20), followed by cardio-respiratory failure (acute respiratory failure n = 4, acute heart failure n = 2), digestive and hepatic disorders (acute hepatitis n = 3, acute pancreatitis n = 2), renal disorders (acute renal failure n = 5) and muscular impairment (rhabdomyolysis n = 3).

CONCLUSION

During the outbreak, hospitalizations were frequent, particularly for common forms, driven by algic clinical presentations and concerns due to the novelty of this infection. Despite atypical neurological and liver forms of CHIKV infection, case-fatality was low in French Guiana. No specific risk factor of atypical and/or severe forms was found in our study.

Epidemiology and Immune Pathogenesis of Viral Sepsis

Sepsis is a life-threatening organ dysfunction caused by a dysregulated host response to infection. Sepsis can be caused by a broad range of pathogens; however, bacterial infections represent the majority of sepsis cases. Up to 42% of sepsis presentations are culture negative, suggesting a non-bacterial cause. Despite this, diagnosis of viral sepsis remains very rare. Almost any virus can cause sepsis in vulnerable patients (e.g., neonates, infants, and other immunosuppressed groups). The prevalence of viral sepsis is not known, nor is there enough information to make an accurate estimate. The initial standard of care for all cases of sepsis, even those that are subsequently proven to be culture negative, is the immediate use of broad-spectrum antibiotics. In the absence of definite diagnostic criteria for viral sepsis, or at least to exclude bacterial sepsis, this inevitably leads to unnecessary antimicrobial use, with associated consequences for antimicrobial resistance, effects on the host microbiome and excess healthcare costs. It is important to understand non-bacterial causes of sepsis so that inappropriate treatment can be minimised, and appropriate treatments can be developed to improve outcomes. In this review, we summarise what is known about viral sepsis, its most common causes, and how the immune responses to severe viral infections can contribute to sepsis. We also discuss strategies to improve our understanding of viral sepsis, and ways we can integrate this new information into effective treatment.

Prevalence and risk factors of post chikungunya rheumatic musculoskeletal disorders: a prospective follow-up study in French Guiana

The estimated seroprevalence in the general population after chikungunya virus (CHIKV) epidemics ranged from 38 to 63%. Despite a low case fatality, subacute and chronic rheumatic forms of CHIKV infection generate significant morbidity and have a socioeconomic impact. The objective of the study was to estimate the prevalence of chronic post-CHIKV rheumatic or musculoskeletal pain (pCHIK-RMSP) at 3 and 6 months after the initial symptoms. An observational study was conducted at Cayenne General Hospital in French Guiana between April 1 and June 30, 2014. All patients seen for CHIKV infection confirmed by RT-PCR were prospectively included. Pregnant women and children under 15 were excluded from the study. All patients were called by phone at 3 and 6 months to enquire about the presence of pCHIK-RMSP. Out of a total of 254 eligible patients, 168 were selected. The mean age was 45.3 years (SD ± 1.4 yo) and the sex ratio (M/F) was 0.75. No death was reported. At 3 months, 40.2% (95% CI 31.1-49.3) of patients (n = 45/112) had pCHIK-RMSP and 31.3% (95% CI 22.2-40.4) of patients (n = 31/99) at 6 months. The median time of end to pain was 2 weeks after the date of onset of signs. The present study provides succinct but informative data about pCHIK-RMSP, which represents the real burden of the disease. There are few studies on that subject in the Amazonian region, but our study shows a lower impact than in the Indian Ocean islands where the population is older.

Ziziphus spina-christi (L.) leaf extract alleviates myocardial and renal dysfunction associated with sepsis in mice

Ziziphus spina-christi (L.), a traditional Arabian medicinal herb, has been used by Egyptians (Bedouin and Nubian) to treat inflammatory symptoms and swellings, pain, and heat since long. We aimed to investigate whether Ziziphus spina-christi leaf extract (ZSCLE) exerted a myocardial and renal protective effect on mice in which sepsis had been induced with cecal ligation and puncture (CLP). Male C57BL/6 mice were divided randomly into six groups (n = 7): sham-operated group, sham-operated mice treated with ZSCLE (300 mg/kg), CLP-induced sepsis group, ZSCLE (100 mg/kg)-treated group, ZSCLE (200 mg/kg)-treated group, and ZSCLE (300 mg/kg)-treated group. Pretreatment with ZSCLE (100, 200, and 300 mg/kg) restored the normal heart rate (HR); decreased the elevated levels of malondialdehyde; the activity of myeloperoxidase, nitric oxide (NO), and inducible NO synthase; and the expression of nuclear factor kappa B (NF-κB), but increased the content of glutathione and antioxidant enzyme activities in mice with sepsis. Moreover, the results of biochemical analyses and qRT-PCR indicated that ZSCLE treatment lowered the level of cytokines, including tumor necrosis factor alpha and interleukin (IL)-1β. Additionally, ZSCLE reduced myocardial and renal apoptosis by inducing the downregulation of caspase-3 and Bax mRNA and upregulation of the expression of Bcl-2. Based on these results, we suggest that ZSCLE has a protective effect against multiple-organ impairment that follows sepsis. This effect may be attributed to the antioxidant, anti-inflammatory, and anti-apoptotic activities of ZSCLE.

The neurological complications of chikungunya virus: A systematic review

We performed a systematic review on the neurological complications of chikungunya virus. Such complications are being reported increasingly, owing primarily to the scale of recent epidemics but also to a growing understanding of the virus' neurovirulence. We performed a thorough literature search using PubMed and Scopus databases, summating the data on all published reports of neurological disease associated with chikungunya virus. We appraised the data for each major condition in adults, children, and neonates, as well as evaluating the latest evidence on disease pathogenesis and management strategies. The review provides a comprehensive summary for clinicians, public health officials, and researchers tackling the challenges associated with this important emerging pathogen.

Chikungunya: Report from the task force on tropical diseases by the World Federation of Societies of intensive and critical care medicine

Chikungunya is an arbovirus that is transmitted by the Aedes mosquito causing a febrile illness with periodic outbreaks in large parts of the world. In the last decade it has become a public health concern in a host of countries and has affected international tourists. In the vast majority of cases Chikungunya presents as an acute febrile illness, associated with rash, headache, myalgia and debilitating arthralgia or even polyarthritis. A small proportion of patients present atypically with nervous, ocular, renal, myocardial, respiratory and renal system involvement and may require ICU management. Over the years the epidemic potential of the virus has become apparent with spread related to an increase in global travel and the successful adaptation of the Aedes mosquito to the urban and sylvan environments in numerous countries. These epidemics have affected millions of people across the globe. Treatment is usually symptomatic and supportive.

Pregnant Women Hospitalized with Chikungunya Virus Infection, Colombia, 2015

Personnel in charge of obstetric populations should watch for cases of chikungunya virus‒induced sepsis with hypoperfusion and organ dysfunction.

In 2015 in Colombia, 60 pregnant women were hospitalized with chikungunya virus infections confirmed by reverse transcription PCR. Nine of these women required admission to the intensive care unit because of sepsis with hypoperfusion and organ dysfunction; these women met the criteria for severe acute maternal morbidity. No deaths occurred. Fifteen women delivered during acute infection; some received tocolytics to delay delivery until after the febrile episode and prevent possible vertical transmission. As recommended by a pediatric neonatologist, 12 neonates were hospitalized to rule out vertical transmission; no clinical findings suggestive of neonatal chikungunya virus infection were observed. With 36 women (60%), follow-up was performed 1 year after acute viremia; 13 patients had arthralgia in >2 joints (a relapse of infection). Despite disease severity, pregnant women with chikungunya should be treated in high-complexity obstetric units to rule out adverse outcomes. These women should also be followed up to treat potential relapses.

Prognostic factors of inhospital death in elderly patients: a time-to-event analysis of a cohort study in Martinique (French West Indies)

OBJECTIVE

The primary objective was to identify predictive factors of inhospital death in a population of patients aged 65 years or older hospitalised with Chikungunya virus (CHIKV) infection. The secondary aim was to develop and validate a predictive score for inhospital death based on the predictors identified.

DESIGN

Longitudinal retrospective study from January to December 2014.

SETTING

University Hospital of Martinique.

PARTICIPANTS

Patients aged ≥65 years, admitted to any clinical ward and who underwent reverse transcription PCR testing for CHIKV infection.

OUTCOME

Independent predictors of inhospital death were identified using multivariable Cox regression modelling. A predictive score was created using the adjusted HRs of factors associated with inhospital death. Receiver operating characteristic curve analysis was used to determine the best cut-off value. Bootstrap analysis was used to evaluate internal validity.

RESULTS

Overall, 385 patients aged ≥65 years were included (average age: 80±8 years). Half were women, and 35 (9.1%) died during the hospital stay. Seven variables were found to be independently associated with inhospital death (concurrent cardiovascular disorders: HR 11.8, 95% CI 4.5 to 30.8; concurrent respiratory infection: HR 9.6, 95% CI 3.4 to 27.2; concurrent sensorimotor deficit: HR 7.6, 95% CI 2.0 to 28.5; absence of musculoskeletal pain: HR 2.6, 95% CI 1.3 to 5.3; history of alcoholism: HR 2.5, 95% CI 1.1 to 5.9; concurrent digestive symptoms: HR 2.4, 95% CI 1.2 to 4.9; presence of confusion or delirium: HR 2.1, 95% CI 1.1 to 4.2). The score ranged from 0 to 25, with an average of 6±6. The area under the curve was excellent (0.90; 95% CI 0.86 to 0.94). The best cut-off value was a score ≥8 points, with a sensitivity of 91% (82%-100%) and specificity of 75% (70%-80%).

CONCLUSIONS

Signs observed by the clinician during the initial examination could predict inhospital death. The score will be helpful for early management of elderly subjects presenting within 7 days of symptom onset in the context of CHIKV outbreaks.

Chikungunya and diabetes, what do we know?

BACKGROUND

Chikungunya (CHIK) is a viral disease transmitted by mosquitoes. The first cases in Brazil were confirmed in 2014. Between 2016 and 2017, over 300,000 cases were identified during this period, with nearly 300 deaths. The clinical manifestations, pathogenesis and risk factors for occurrence of severe cases are not yet well understood, although it is known that the severity of the cases is associated with the presence of comorbidities, especially diabetes mellitus (DM).

OBJECTIVE

To review the medical literature for the associations between DM and CHIK and to understand the potential impact on metabolic state and its complications.

METHODS

Literature review was carried out to search for articles (English, Portuguese and Spanish) in Medline and Virtual Health Library databases for the period between 1952 and 2017, with the following keywords: "Chikungunya fever", "Chikungunya virus", "diabetes mellitus", "diabetes", "diabetes complications "and "multi-morbidities (MeSH) "with interposition of the Boolean operator "AND".

RESULTS

After removal of duplicities and following exclusion criteria, 11 articles were selected. Our results showed that the patients of CHIK with DM had more severe and prolonged symptoms of CHIK and more frequently required hospitalization. No study investigated the biological process to explain how hyperglycemic state worsened the clinical manifestations of Chikungunya in diabetic patients.

CONCLUSION

An important association between DM and the severity of CHIK is observed. Prospective and more rigorous controlled studies are required to generate evidence that might y elucidate the causes of this relationship. Given the fast expanding viral infection of Chikungunya in Central and South America, Asia and Africa in recent years in the context of exponential increase in diabetes globally, the issue deserves global attention.

Severity of acute Zika virus infection: A prospective emergency room surveillance study during the 2015-2016 outbreak in Suriname

Acute Zika virus (ZIKV) infection is usually mild and self-limiting. Earlier, we reported three cases of fatal acute ZIKV infection in patients without typical signs of ZIKV, but rather with criteria of systemic inflammation response syndrome (SIRS). To follow up these observations, we prospectively included patients at the emergency room with temperature instability and suspected to have acute ZIKV infection, SIRS, or both. A total of 102 patients were included of whom N = 21 (21%) were suspected of acute ZIKV infection, N = 56 (55%) of acute ZIKV infection with SIRS criteria, and N = 25 (24%) of SIRS alone. ZIKV-PCR was positive in N = 21 (20%) patients. Eight (38%) ZIKV-positive patients needed admission to the hospital of whom four (50%) presented with SIRS alone. One ZIKV-positive patient had vascular co-morbidity and died following shock and severe coagulopathy. We confirm the hypothesis that acute ZIKV infection can present atypical and severely with systemic inflammation and have lethal course particularly amongst patients with significant prior disease.

Chikungunya Virus Infection: Why Should U.S. Geriatricians Be Aware of It?

Chikungunya virus (CHIKV) was until recently perceived only as a tropical disease. Since the first report of a case in Saint Martin Island in 2013, it has spread to South, Central, and North America. The first local transmission in the continental United States was reported in Florida in July 2014. CHIV infection is known to cause debilitating rheumatologic disease. Older adults are particularly susceptible to severe and chronic infection. Without an effective vaccine and antiviral therapy to prevent and control CHIKV, U.S. geriatricians could soon be confronted with major clinical, functional, and therapeutic challenges. After a general overview of CHIKV infection, this review will examine reasons why it has become such a threat to the United States and consider factors that contribute to the greater burden and effect of this disease in elderly adults. Consideration will be given to how aging and immunosenescence may contribute to CHIKV's atypical and more-severe clinical features in older adults. This review concludes with possible therapeutic approaches that best fit the unique needs of older adults, especially with regard to multimorbidity and polypharmacy.

Guillain-Barré Syndrome and Chikungunya: Description of All Cases Diagnosed during the 2014 Outbreak in the French West Indies

The Guillain-Barré syndrome (GBS) has been reported as a possible complication of acute chikungunya infection. The chikungunya epidemics, which occurred in Martinique and Guadeloupe in 2014, affected 308,000 people in these two islands. GBS occurred during or immediately after acute chikungunya infection in 13 patients (10 men, three women; mean age: 61 years). Median time from acute chikungunya to GBS onset was 9 days. Twelve patients were treated with intravenous polyvalent immunoglobulins, nine of whom improved within 7 days. Five of 13 patients required mechanical ventilation. Two patients with severe GBS died. At 6 months of follow-up, 7/13 achieved a good functional recovery with no or minor residual symptoms. A 2-fold increase in incidence was observed during the year of chikungunya outbreak. This study supports prior reports suggesting that GBS may be a complication of chikungunya.

Levels of insecticide resistance to deltamethrin, malathion, and temephos, and associated mechanisms in Aedes aegypti mosquitoes from the Guadeloupe and Saint Martin islands (French West Indies)

Background

In the Guadeloupe and Saint Martin islands, Aedes aegypti mosquitoes are the only recognized vectors of dengue, chikungunya, and Zika viruses. For around 40 years, malathion was used as a mosquito adulticide and temephos as a larvicide. Since the European Union banned the use of these two insecticide molecules in the first decade of the 21st century, deltamethrin and Bacillus thuringiensis var. israelensis are the remaining adulticide and larvicide, respectively, used in Guadeloupe. In order to improve the management of vector control activities in Guadeloupe and Saint Martin, we investigated Ae. aegypti resistance to and mechanisms associated with deltamethrin, malathion, and temephos.

Methods

Ae. aegypti mosquitoes were collected from six different localities of Guadeloupe and Saint Martin. Larvae were used for malathion and temephos bioassays, and adult mosquitoes for deltamethrin bioassays, following World Health Organization recommendations. Knockdown resistance (Kdr) genotyping for V1016I and F1534C mutations, and expression levels of eight enzymes involved in detoxification mechanisms were examined in comparison with the susceptible reference Bora Bora strain.

Results

Resistance ratios (RR₅₀) calculated for Ae. aegypti larvae showed high resistance levels to temephos (from 8.9 to 33.1-fold) and low resistance levels to malathion (from 1.7 to 4.4-fold). Adult females displayed moderate resistance levels to deltamethrin regarding the time necessary to affect 50% of individuals, varying from 8.0 to 28.1-fold. Molecular investigations on adult mosquitoes showed high resistant allele frequencies for V1016I and F1534C (from 85 to 96% and from 90 to 98%, respectively), as well as an overexpression of the glutathione S-transferase gene, GSTe2, the carboxylesterase CCEae3a, and the cytochrome genes 014614, CYP6BB2, CYP6M11, and CYP9J23.

Conclusions

Ae. aegypti populations from Guadeloupe and Saint Martin exhibit multiple resistance to organophosphates (temephos and malathion), and pyrethroids (deltamethrin). The mechanisms associated with these resistance patterns show strong frequencies of F1534C and V1016I Kdr mutations, and an over-expression of CCEae3a, GSTe2, and four cytochrome P450 genes (014614, CYP9J23, CYP6M11, CYP6BB2). These results will form the baseline for a deeper understanding of the insecticide resistance levels and associated mechanisms of Ae. aegypti populations and will be used to improve vector control strategies in Guadeloupe and Saint Martin.

Electronic supplementary material

The online version of this article (doi:10.1186/s40249-017-0254-x) contains supplementary material, which is available to authorized users.