Case Presentation: 68 year-old female presented with three days of progressively worsening myalgias, headaches, fevers after a cruise through Antica, Saint Martin, and Puerto Rico (PR). She also was confused and unable to walk. She had no neck stiffness or photophobia. On exam, she was alert and oriented to name only, with temperature 103 Fahrenheit. Babinski and Kernig’s signs were negative.Motor power in bilateral lower extremities was 4/5. Brain magnetic resonance imaging revealed no abnormalities. Given high suspicion for meningitis, broad-spectrum antibiotics (ceftriaxone, vancomycin, ampicillin) and acyclovir were started imperically. After multiple unsuccessful attempts, lumbar puncture was performed and cerebrospinal fluid (CSF) showed white blood cell 190 with 89% lymphocytes, CSF glucose 31, and CSF protein 98. CSF cultures and basic viral panel were negative. Further studies were sent to investigate other etiologies; Cryptococcus, Aspergillosis, Dengue, Zika, and Chikungunya viruses. Given clinical improvement, patient was discharged with intravenous ceftriaxone, vancomycin, ampicillin and acyclovir. After discharge, Chikungunya antibody IgM was detected (1.17, reference lab < 0.90). Post-discharge follow up indicated full recovery of mental status and no neurological sequelae.
Discussion: Chikungunya virus is a mosquito-transmitted (typically Aedes aegypti and albopictus), alpha-virus belonging to the Togaviridae family. Typically causing a febrile illness associated with arthralgia and arthritis three to seven days after bitten. While in the US, travel-associated cases are typical (N=248 in 2016). However, in territories like PR and US Virgin Islands, local-transmitted cases are more common (N=179 in 2016). Though infections with Chikungunya virus are short-lived within a week, symptoms can be debilitating and severe, especially with neurologic manifestations including encephalitis, myelitis and Guillian-Bare syndrome (GBS). Some cases even present with psychosis. When suspected patients who traveled in endemic areas have CSF findings consistent with viral infections (typically normal-elevated protein, normal glucose, and cytology count > 5 cells/mm3, predominantly lymphocytes or mononuclear cells), Chikungunya RNA should be part of the work up since CSF fluid viral load is high in the early phase (< 3 days after illness onset). IgM antibodies are detectable four to eight days after the onset of symptoms and can persist for several weeks to months. It is imperative to identify infections like Chikungunya to avoid transmissions via mosquito bites, especially in summer months. Treatments typically are symptomatic with hydration along with antipyretic/analgesic. However, if neuromanifestations are consistent with GBS symptoms, then intravenous immunoglobulin or plasmapheresis and/or corticosteroid pulse should be indicated. Vaccines and antiviral therapy are currently in different stages of development.
Conclusions: 1. Identify preliminary diagnosis and endemic exposure areas to Chikungunya viruses, often based on clinical features, places and dates of travel along with activities.2. Recognize signs and symptoms of neuromanifestations of viral mengingitis to prevent fatal outcomes and transmission cycle.
References:
Brizzi, K. (2017). Neurologic Manifestation of Chikungunya Virus. CIDR, 19(6), 1-6.
Chikungunya Virus. (2017). www.cdc.gov
Pinheiro, T. J., etc. (2016). Neurological manifestations of Chikungunya and Zika infections. 937-943.