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Chikungunya Virus Fever/Rash/Arthritis

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Chikungunya Virus Fever/Rash/Arthritis 9/27/15 Emerging Infections: Ebola & Chikungunya Chikungunya Virus Elizabeth Race, MD, MPH Infectious Diseases / HIV Medicine AIDS Healthcare Foundation, Dallas, Texas Chikungunya Virus: A Newly Re-emergent Infectious Problem Fever/Rash/Arthritis • Arbovirus originally identified in 1950s in E. Africa, in sylvatic cycle involving primates and forest mosquitoes -Triad of fever/rash/arthritis is characteristic of Chikungunya, O’nyong-nyong, Ross River, Mayaro, • Clinical descriptions first in 1970s in South Africa and Sindbis viruses • Limited outbreaks periodically in SE Asia, with a larger one -Symptoms generally appear after 2-3 days incubation in 2001-2003 in Indonesia (after 20-year hiatus) a) fever, chills, myalgia b) polyarthralgia mainly affecting small joints • Explosive outbreak in 2005-present, in Indian Ocean c) maculopapular rash islands & Indian subcontinent, involving millions of cases -Arthritis generally resolves in a few weeks, but may • Imported cases in Europe, North America among travelers persist for months, or years in some cases. to Indian Ocean sites Aedes albopictus • Genus Alphavirus; Family Togaviridae • First isolated from the blood of a febrile patient in Tanzania in 1952 • Identified repeatedly in west, central and southern Africa and many areas of Asia • Transmitted by A. aegypti, A.albopictus, others; vertebrate hosts include primates Charrel R et al. N Engl J Med 2007;356:769-771 1 9/27/15 World Distribution of the Aedes albopictus Togaviridae, genus Alphavirus Charrel R et al. N Engl J Med 2007;356:769-771 Chikungunya • Acute chikungunya fever typically lasts a few days to a couple of weeks, but some patients have prolonged fatigue lasting several weeks • Up to 10% may develop chronic joint symptoms • Infection can cause a debilitating illness, most often characterized by fever, headache, • Death is very uncommon fatigue, nausea, vomiting, muscle pain, rash, and joint pain. The term ‘chikungunya’ is • No vaccine or preventive drug; recommendation: Swahili for ‘that which bends up.’ vector control, vector avoidance Skin manifestations in CHIKV in travelers Hochedez P, Jaureguiberry S, Debruyne M, Bossi P, Hausfater P, Brucker G, et al. Chikungunya infection in travelers. Emerg Infect Dis. 2006 Oct From: Medicine 2007;86:123-137 2 9/27/15 Chikungunya tenosynovitis, arthritis MRI: arthritis, tenosynovitis From: Medicine 2007;86:123-137 Figure: WHO; http://www.who.int/csr/don/Regional_Chykungunya_largeb.jpg Chikungunya Outbreaks: Chikungunya Infection in Travelers • India (14 states), Malaysia, Indonesia, Sri Lanka, Maldives, Nicobar Islands • Imported cases reported in multiple countries: – Australia – Japan During 2005-’06, 12 cases of CHIK – Taiwan fever were dx’d serologically and virologically at CDC in travelers who – Europe: UK, France, Italy, Spain arrived in the US from areas known to – USA be epidemic or endemic for CHIKV Hochedez P, Jaureguiberry S, Debruyne M, Bossi P, Hausfater P, Brucker G, et al. Chikungunya infection in travelers. Emerg Infect Dis. 2006 Oct Chikungunya Virus: Summary • Caused by virus inoculated via mosquito bites – Increased risk May-October (rainy season) – Increased risk in urban and village areas African Tick-Bite Fever • Symptoms: Sudden onset of fever, rash on trunk and limbs, back pain, and severe joint pain / arthritis in multiple joints • Treatment: analgesics, NSAIDS, corticosteroids; chloroquine has been used in a few refractory cases Rickettsia africae • Countermeasures – Prevent mosquito bites – Use insect repellent – Sleep under a permethrin-treated bed net 3 9/27/15 Spotted Fever Group Disease: African Tick-Bite Fever Mediterranean spotted fever - Rickettsia (R.) conorii • Rickettsial infections: R africae & R conorii Rickettsialpox - R. akari African tick bite fever - R. africae • Transmitted by ticks Queensland tick typhus - R. australis Japanese spotted fever - R. japonica • 1992: Kelly et al isolated R africae from a Flinders Island spotted fever - R. honei patient in Zimbabwe (Lancet 340:982-983) California flea rickettsiosis - R. felis Siberian tick typhus - R. sibirica • Exported from southern Africa [ & Israeli spotted fever - not named Guadeloupe] to US 1997 Astrakhan fever - not named (Am J Trop Med Hyg1999;60(5):865-7; France 1998 (CID 1998;27(2): 316-23); France 2001 (NEJM 2001;344(20);1504-10) Italy 1999 (EJCMID 2002;21(2): 133-6) Norway 2003 (CID 2003;36(11):1411-7) African Tick Bite Fever • Seroprevalence of R. africae in ticks approx. 27-50% • Amblyomma ticks (found on cattle & ungulates) • Exposure: walking through brush/cattle areas • Usual incubation period 6-7d, varies, most in 2 wks • Fever, H/A, adenopathy, occ. RUQ pain, rash • Single or multiple eschars (vesicular) • Diagnosis: PCR, MIF, Western Blot, culture • Complications unusual • Therapy: doxycycline (possibly single-dose) Amblyomma variegatum (female). Parola P, Raoult D. et al. Am J Trop Med Hyg 1999;60:888-93. PHILIPPE PAROLA, GUY VESTRIS, DOMINIQUE MARTINEZ, BERNARD BROCHIER, VERONIQUE ROUX, DIDIER RAOULT. Am. J. Trop. Med. Hyg., 60(6), 1999, pp. 888–893 Four Inoculation Eschars (Arrows) on the Legs of a Patient Who Presented with Tick Borne Rickettsial Lesions: African Tick-Bite Fever after Returning from a Safari in South Africa “Tache noire” Raoult D et al. N Engl J Med 2001;344:1504-1510 4 9/27/15 Figure 1. Fibrinoid necrosis of a vessel in the dermis (arrow) with Figure 3. Inoculation eschar from a patient with African tick-bite perivascular inflammatory infiltrates mainly composed of fever showing numerous dermal inflammatory infiltrates mainly polymorpho-nuclear leukocytes (hematoxylin-eosin-saffron; orig. composed of polymorphonuclear leukocytes (immunoperoxidase magnification ×250). staining with an anti-CD15 antibody; original magnification ×100). Hubert Lepidi,Pierre-Edouard Fournier,& Didier Raoult,Université de la Méditerranée, Marseille, France Vol.12,No. Hubert Lepidi,Pierre-Edouard Fournier,& Didier Raoult,Université de la Méditerranée, Marseille, France Vol.12,No. 9 Sept2006 9 Sept2006 Clinical Characteristics of R.africae infection • Fever > 38.5 • 88% • Neck myalgias • 81% • Inoculation • 95% eschars • 54% • Multiple eschars • 43% • Lymphadenopathy • 46% (45%) • Rash (vesicular) Figure 5. Immunohistochemical detection of Rickettsia africae in • 0% the inoculation eschar of a pt with African tick-bite fever. Note • Death location of the bacteria in the endothelial and inflammatory cells of a blood vessel in the dermis (arrow);monoclonal rabbit anti-R. Raoult D, et al. NEJM 2001;344:1504-10. africae antibody used at a dilution of 1:1,000 & hematoxylin counterstain; orig. magnification ×250. Hubert Lepidi,Pierre-Edouard Fournier,& Didier Raoult,Université de la Méditerranée, Marseille, France Vol.12,No. 9 Sept2006 Rickettsial Disease in the Treatment of African Tick Bite Fever Returning Traveler (Lyme, RMSF, Ehrlichia) • R.africae > murine typhus (R.typhae) > mediterranean spotted fever > scrub typhus • Also RMSF, epidemic typhus, N. Asian, doxycycline Queensland tick typhus • Approx. 3rd most likely etiology of fever in the returning traveler after malaria and typhoid fever Jensenius M, et al. Clin Infec Dis 2004;39:1493-9; Intl J Infec Dis 2004;8:139-46. 5 9/27/15 Emerging Infections: Ebola Virus Disease Viral Hemorrhagic Fevers Flaviviridae (dengue, yellow fever, TBE encephalitides) Arenaviridae (Lassa, Junin, Machupo, Guanarito) Enveloped RNA viruses Bunyaviridae Filoviridae (CCHF, RVF, (Ebola, Marburg) Hantaviruses) Ebola Taxonomy Scientific Classification Order: Mononegavirales Family: Filoviridae Genus: Ebola like viruses Species: Ebola Subtypes – Ebola-Zaire, Ebola-Sudan,Ebola-Ivory Coast Copyrighted Dr. Fre:derick A. Murphy, D.V.M., Ph.D. 1976. • disease in humans – Ebola-Reston • disease in nonhuman primates • Ebola virus and Marburg virus are most well known and studied • Other viruses: Sudan virus, Bundibugyo virus, Tai Forest virus, Reston virus, Ravn virus Viruses without borders Ebola Virus q Prototype Viral Hemorrhagic q >20 previous Ebola and Fever Pathogen Marburg virus outbreaks § Filovirus: enveloped, q 2014 West Africa Ebola non-segmented, negative- stranded RNA virus outbreak caused by Zaire ebolavirus species § Severe disease with high case fatality (five known Ebola virus species) § Absence of specific treatment or vaccine 36 6 9/27/15 Epidemiology and ecology are intimately linked Ebola Virus q Zoonotic virus – bats the most likely reservoir, although species unknown q Spillover event from infected wild animals (e.g., fruit bats, monkey, duiker) to humans, followed by human-human transmission 37 Current Ebola virus outbreak Figure. Ebola virus disease (EVD) cumulative incidence* — West Africa, October 18, 2014 * Cumulative number of reported EVD cases per 100,000 persons since December 22, 2013. MMWR 2014;63(43):978-981 (graphics: BBC) 40 2014 Ebola Outbreak, West Africa EVD Cases and Deaths* Reporting Confirmed Total Cases Total Deaths Date Cases Guinea 27 Oct 14 1,906 1,391 997 Liberia 25 Oct 14 6,535 2,515 2,413 Sierra Leone 27 Oct 14 5,235 3,700 1,500 Nigeria** 15 Oct 14 20 19 8 Spain 27 Oct 14 1 1 0 Senegal** 15 Oct 14 1 1 0 United States 24 Oct 14 4 4 1 Mali 23 Oct 14 1 1 1 TOTAL 13,733 7,632 4,920 Updated case counts available at http://www.cdc.gov/vhf/ebola/outbreaks/2014-west-africa/case-counts.html. WHO Ebola Response Team. N Engl J Med 2014. DOI: 10.1056/NEJMoa1411100 *Reported by WHO using data from Ministries of Health http://www.nejm.org/doi/full/10.1056/NEJMoa1411100?query=featured_ebola#t=articleResults
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