|Year : 2017 | Volume
| Issue : 3 | Page : 167-168
Clinical questions: Responses to clinical queries from readers: Chikungunya
Tarun K George, Ashish Jacob Mathew
Department of Medicine, Christian Medical College, Vellore, Tamil Nadu, India
|Date of Web Publication||7-Aug-2017|
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
George TK, Mathew AJ. Clinical questions: Responses to clinical queries from readers: Chikungunya. Curr Med Issues 2017;15:167-8
What can be done to patients who had chikungunya and now suffering from severe pain in metacarpophalangeal, metatarsal joints, wrist elbow, and shoulder? This pain is quite disabling as they cannot carry out any work. Some of the patients have undergone all sorts of investigations and different pain killers. The diagnosis was confirmed at local medical college. Age of patients is from 20 to 60 years and both males and females. Kindly provide suggestion from Christian Medical College doctors.
Post-chikungunya (CHIK) chronic musculoskeletal disorders are an ill-defined entity. The arthritis and myalgias can be long lasting, and there are no clearly defined criteria for this. It is possible that the viral infection also triggers the onset of rheumatoid arthritis (RA) and spondyloarthritis. These patients can also have enthesitis, bursitis, and tunnel syndromes. There are studies that have described the various musculoskeletal manifestations and possible treatments for the same.,,,, Although this is not validated, a practical approach for these (adult) patients can be the following:
Active chickungunya infection with polyarthralgia and arthritis:
- Escalating regimens of the following based on pain relief and comorbidities
- Paracetamol 1 g prn and up to three times a day–monitor liver function test if doses are high
- Nonsteroidal anti-inflammatory drugs (NSAIDs) – preferentially gastroprotective (caution if there is cardiac risk). Can also use any NSAID with proton pump inhibitors at maximal dose up to 3–4 weeks
- Steroid – Prednisolone 10 mg once a day (if contraindication or not tolerating NSAID or concerned about renal/gastrointestinal side effects). Equivalent doses of deflazocortisone can also be used. This can be tapered over 1–2 months based on the clinical response
- If there is a significantly inflamed joint, intra-articular steroid injection can be considered
- Most patients will recover with this treatment. Avoiding using both NSAID and steroid in patients with gastric complaints. Paracetamol and steroids are better tolerated. Monitor sugars when starting steroid in diabetics.
Arthritis beyond 6 weeks:
- If the arthritis continues to be prominent beyond 6 weeks, it is unlikely to subside soon. One should also carefully distinguish whether the pain is extra-articular as fibromyalgia and tenosynovitis can also present in this group of patients
- These present like a RA pattern or spondyloarthritis pattern
- Consider steroids at the above-mentioned dose
- Initiate methotrexate and hydroxychloroquine (HCQ) in a similar regimen as RA
From this stage on they may be treated as a case of RA with escalating doses of methotrexate, sulfasalazine, and HCQ. Adequate pain relief and anti-inflammatory action should be provided for at least 2 months as disease-modifying anti-rheumatic drugs (DMARDs) take several weeks to have an anti-inflammatory effect.
For longer lasting polyarthritis - evaluate for new onset RA of spondyloarthritis.
Often they may not fulfil the criteria in which case they may be labeled as chronic inflammatory rheumatism. These patients can progress to develop erosive arthritis in post-CHIK arthritis. Hence, they would benefit from DMARD therapy.
If there is features of neuropathic pain, consider tricyclic antidepressants such as amitriptyline at 10–25 mg at night and increase weekly up to 50–75 mg based on response. If there is features of fibromyalgia consider pregabalin 75 mg at night and increase if response is not achieved.
Reassure the patient that treatment is available for the pain. Treat the pain and inflammation. Refer if pain is not resolving. Monitor for side effect of therapy used.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Javelle E, Ribera A, Degasne I, Gaüzère BA, Marimoutou C, Simon F. Specific management of post-chikungunya rheumatic disorders: A retrospective study of 159 cases in Reunion Island from 2006-2012. PLoS Negl Trop Dis 2015;9:e0003603.
Ganu MA, Ganu AS. Post-chikungunya chronic arthritis – Our experience with DMARDs over two year follow up. J Assoc Physicians India 2011;59:83-6.
Mathew AJ, Goyal V, George E, Thekkemuriyil DV, Jayakumar B, Chopra A; Trivandrum COPCORD Study Group. Rheumatic-musculoskeletal pain and disorders in a naïve group of individuals 15 months following a chikungunya viral epidemic in South India: A population based observational study. Int J Clin Pract 2011;65:1306-12.
Schilte C, Staikowsky F, Couderc T, Madec Y, Carpentier F, Kassab S, et al.
Chikungunya virus-associated long-term arthralgia: A 36-month prospective longitudinal study. PLoS Negl Trop Dis 2013;7:e2137.
Mathew AJ, Ganapati A, Kabeerdoss J, Nair A, Gupta N, Chebbi P, et al.
chikungunya infection: A global public health menace. Curr Allergy Asthma Rep 2017;17:13.