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ORIGINAL ARTICLE
Year : 2011  |  Volume : 56  |  Issue : 3  |  Page : 290-294
Mucocutaneous manifestations of chikungunya fever: A study from an epidemic in coastal Karnataka


1 Department of Dermatology, Venereology and Leprosy, Fr Muller Medical College, Mangalore-2, India
2 Department of Periodontology, AB Shetty Institute of Dental Sciences, Deralakatte, Mangalore, India

Date of Web Publication30-Jun-2011

Correspondence Address:
Ramesh M Bhat
Department of Dermatology, Venereology and Leprosy, Fr Muller Medical College, Kankanady, Mangalore- 2, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-5154.82483

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   Abstract 

Background : Chikungunya fever (CF) epidemic has recently re-emerged in India affecting large population. Mucocutaneous manifestations are an important clinical feature of the disease. We have reviewed mucocutaneous manifestations of the disease during a recent epidemic in coastal Karnataka. Patients and Methods Seventy-five "suspect cases" of CF with dermatological manifestations were examined. Results : We categorized the mucocutaneous manifestation into six groups: 1. skin rash, 2. apthae like ulcers, 3. pigmentary changes, 4. desquamation, 5. exacerbation of the existing dermatoses, 6. miscellaneous. Skin rashes were the most commonly observed skin changes followed by apthae like ulcers and pigmentary changes. Desquamation of the skin over the face is a new manifestation observed by us. Conclusion : wide spectrum of mucocutaneous manifestations is observed in CF. We have provided a classification for these manifestations, which may help in better recognition and uniform recording in future.


Keywords: Chikungunya fever, mucocutaneous manifestations, maculopapular rash


How to cite this article:
Bhat RM, Rai Y, Ramesh A, Nandakishore B, Sukumar D, Martis J, Kamath GH. Mucocutaneous manifestations of chikungunya fever: A study from an epidemic in coastal Karnataka. Indian J Dermatol 2011;56:290-4

How to cite this URL:
Bhat RM, Rai Y, Ramesh A, Nandakishore B, Sukumar D, Martis J, Kamath GH. Mucocutaneous manifestations of chikungunya fever: A study from an epidemic in coastal Karnataka. Indian J Dermatol [serial online] 2011 [cited 2017 Oct 17];56:290-4. Available from: http://www.e-ijd.org/text.asp?2011/56/3/290/82483



   Introduction Top


Chikungunya literally means "that which bends up" in the makonde language, probably coined because of the severe prolonged incapacitating arthritis associated with the disease. [1] Chikungunya fever (CF) is caused by Chikungunya virus (CHIK V) (family togaviridae, genus alphavirus) which is transmitted by the bite of infected Aedes aegypti and Aedes albopicus mosquitoes. [2] The first description of CF was made during the outbreak on the Makonde plateau along the border between Tanganyika and Mozambique in 1952 and the virus was isolated from both mosquito and man. Since then, many epidemics of CF have been reported, mainly from Africa and different Asian countries. The disease first appeared in India in 1963; it caused very extensive epidemic in Kolkata (then Calcutta), [3] Tamilnadu (then Madras) and Andhra Pradesh. This was followed by an outbreak in Maharashtra in 1973. [4] The disease re-emerged after a gap of nearly 32 years in different parts of India in December 2005. [5] An epidemic of CF broke in the coastal districts of Karnataka in 2008 and a total of 39,042 cases were suspected to have this disease according to the statistics provided by the district health authorities.

The incubation period of CF is from 2 to 4 days. The clinical manifestations of the disease include high fever upto 40ΊC (104ΊF), a petechial or maculopapular rash of trunk and occasionally limbs, and polyarthritis/arthralgia. There are marked constitutional symptoms like intense headache, insomnia and an extreme degree of prostration lasting for a variable period, usually for about 5-7 days. The disease is self-limiting, lasting for a period of 1-7 days; however, condition is associated with significant morbitity related to persistent arthritis and long-term anti-inflammatory therapy. [6] Specific treatment is not available for CF at present, and patients are treated symptomatically. [7]

The mucocutaneous manifestations of the disease include facial flush, fine discrete morbilliform exanthema and, occasionally, purpura has been reported. [8] During the present epidemic of CF in India, several other cutaneous manifestations have been reported with this disease. [4],[7],[9] We conducted a study to document the various patterns of mucocutaneous manifestations of the disease during an epidemic in coastal Karnataka.


   Patients and Methods Top


Seventy-five consecutive patients with mucocutaneous manifestations of suspect cases of CF, fulfilling the "case definition" of the National institute of communicable disease, Directorate General of Health Science, Government of India, were included in this study. "Suspect cases" have been defined as patients presenting with an acute illness characterized by the sudden onset of fever, with several symptoms such as joint pain, headache, backache, photophobia and eruption during an epidemic of CF and in the absence of confirmatory serologic tests. [7] These guidelines were followed for "suspect" cases of CF with mucocutaneous manifestations, examined over a period of 3 months (June-August 2008) in the dermatology department of Fr Muller Medical College Hospital, Mangalore, a tertiary care hospital in coastal Karnataka, South India. There was an epidemic of CF during this period. These patients either reported voluntarily because of their skin lesions or referred by other departments.

A detailed history with a special emphasis on the nature of fever, joint pain and appearance of the skin lesion was taken. Clinical examination was performed and the findings were recorded. Drug reactions and other viral exanthema were ruled out by careful history, clinical features and investigations including serology for dengue fever in cases of hemorrhagic rashes. Laboratory investigations performed in all included blood counts and urine analysis. Other investigations were performed in patients with severe disease.


   Results Top


A total of 75 patients of "suspect" cases of CF with mucocutaneous manifestations were examined. Frequent age distribution in our series was 31-40 and 41-50 years, with the number of cases being 21 (28%) and 15 (20%), respectively [Table 1]. There were 68 adult patients and 7 pediatric patients. Males and females were almost equally affected (males 37; females 38). One hundred and ninety-six patients were reported as "suspect" cases of chikungunya in our hospital during the study period, of whom 75 (38.26%) presented with mucocutaneous manifestations. Fifty-five patients were treated on an out-patient basis and 20 patients as in-patients. All the in-patients were referred from other departments.
Table 1: Age distribution


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The cutaneous lesions observed in these patients, together with their average duration, are presented in [Table 2]. The patients presented with either a single or multiple type of skin lesions. As shown in the table, we categorized the mucocutaneous manifestations into the following six major categories:
Table 2: Mucocutaneous manifestations of CF


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  1. skin rash;
  2. apthae like ulcers;
  3. pigmentary changes;
  4. desquamation;
  5. exacerbation of the existing dermatoses and
  6. miscellaneous, i.e. urticaria, non-intertriginous necrotic cutaneous ulcers, scrotal dermatitis, pedal edema and vesiculobullous eruption.


Skin rash

This was the most common manifestation of CF in our study [Figure 1] and seen in 39 patients (52%). Morbilliform/maculopapular exanthematous rashes were seen in 24 patients. Facial flushing was seen in seven patients. Erythematous macular rashes were seen in five patients. Hemorrhagic lesions like purpura and ecchymosis were also seen in a few patients. These rashes appeared in the early phase of the disease (1-7 days).
Figure 1: Ecchymotic rash

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Apthae like ulcers

These were seen not only on the oral mucosa but also on the axillae and groins. These ulcers were seen in 17 patients (22.66%) and were the second most common mucocutaneous manifestations observed. Oral ulcers were seen in 12 patients, ulcers in the axillae were seen in 3 and ulcers in the groin in 2 patients. These ulcers were also seen during the acute phase of the disease (2-7 days). The ulcers were multiple, inflammatory, tender, punched out, small ulcers (2-5 mm in size) and covered with slough.

Pigmentary changes

Pigmentary changes [Figure 2] were noted in 12 patients (16%). Diffuse hyperpigmentation of the face was seen in nine patients. Two patients had centrofacial pigmentation. Hyperpigmentary changes were seen later in the disease after the subsidence of fever (1-2 weeks). These patients also complained of photosensitivity. Pigmentation was diffuse. It is interesting to note that one patient developed hypopigmented macules on the face.
Figure 2: Centrofacial hyperpigmentation

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Desquamation

Scaling of the skin over palms, soles and face was observed in eight patients (10.66%). This was also observed during the 2nd week of the illness.

Exacerbation of the existing dermatoses

Exacerbation of the existing dermatological disease was observed in four patients (5.33%). Two of them had exacerbation of psoriasis and one each had exacerbation of eczema and erythroderma.

Miscellaneous

Other cutaneous manifestations observed in our patients include vesiculobullous lesions and pedal edema in four patients each (5.33%), urticaria in three (4%) patients, non-intertriginous necrotic cutaneous ulcers in two (2.66%) patients [Figure 3] and scrotal dermatitis in one (1.33%) patient.
Figure 3: Scrotal ulcers

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All the patients with mucocutaneous manifestations were treated symptomatically and responded satisfactorily.


   Discussion Top


CF epidemics are characterized by explosive outbreaks interspersed by periods of disappearance that may last from several years to a few decades. [2] Even though the present outbreak in India started in December 2005, it affected coastal Karnataka in the year 2008 only. According to the data provided by the district health officials, a total of 130,982 fever cases were reported during this period and 39,042 cases fulfilled the criteria for "suspect cases" of CF. The disease in the region was confirmed by viral serological studies.

The present study reviewed the various mucocutaneous manifestations of the disease, which were observed to occur in 40-50% of all cases in previous reports. [10] In our study, the frequency of mucocutaneous manifestations in CF was about 38%. However, this may not reflect the true incidence of cutaneous manifestations as the study was conducted in a tertiary care hospital. There are a few studies pertaining to mucocutaneous manifestations in CF. [4],[7],[8] Probably, this is the second comprehensive report on mucocutaneous manifestations of CF from Karnataka. Inamdar et al. [7] in their study from Bijapur of North Karnataka situated nearly 400 km away from Mangalore of coastal Karnataka, reported 145 cases of CF with cutaneous manifestations.

We have made an attempt to classify the mucocutaneous manifestations of CF into six major categories. Skin rashes including exanthema, classical of many viral fevers is the most common cutaneous manifestation observed in our study. However, hyperpigmentation was the most common cutaneous finding in the report by Inamdar et al. [7]

A generalized maculopapular eruption is the most common cutaneous manifestation described in association with CF. During an epidemic in South Africa, 86% of the patients presented with this feature. [8] It is usually seen during acute phase of the disease. Recurrent crops of maculopapular eruptions can occur due to successive crops of viremia. [10] All our patients with skin rashes had it during the acute phase of the illness. Facial flushing, macular erythema, hemorrhagic rashes, more classically seen in dengue fever, were also seen in CF. Hemorrhagic rashes, seen in nearly 41.1% cases of dengue, [11] is less frequently seen in CF. Even though sparing of face and involvement of trunk and limbs have been reported by Hochedz et al., [12] we did not find facial spare. Bandyopadhyay and Ghosh have also reported involvement of face in their case series. [4] Exanthema in our patients caused mild itching, and burning sensation was complained by febrile patients. Because of the intense erythema produced by exanthema, which is obvious in fair skinned individuals, CF is popularly called as "tomato fever" by local people. Oral apthae and apthae like ulcers of the intertriginous areas were seen in 22.66% of our patients. Apthae like ulcers, occurring mostly in the perineum, groins and axillae, is an observation made during this epidemic in India. [7],[9] It was observed in 21.38% of patients in the series reported by Inamdar et al. In our case series, oral apthae were more common than the apthae like ulcers in the intertriginous areas. Similar finding was observed in the study by Bandyopadhyay and Ghosh. [4] In contrast, Inamdar et al. reported only 1 patient with oral apthae among 31 patients with apthae like ulcers. [7] In yet another report from central India, 16 young adult males with penoscrotal ulcerations were reported. [9] Even though oral apthae were observed in both the sexes, ulcers in the intertriginous areas were observed only in males with CF. It is interesting to note that ulcers in the groin has been observed only in male patients in all the reported case series so far. Pigmentory changes mainly involving the face are seen in patients with CF. It was the third most common cutaneous manifestation in our series in contrast to the study by Inamdar et al. who reported it as the most common manifestation. It was seen in 16.33% of patients as compared to 42% in the report by Inamdar et al. [7] We observed brownish black diffuse pigmentation, mainly involving the nose and centrofacial areas. Pigmentation usually occurred after subsidence of fever, which prompted the patient to consult a dermatologist. Most of these patients had exacerbations of the pigmentation on exposure to the sunlight. One of our patients had hypopigmented macules on the face. Hypopigmentation was preceeded by peeling of the skin on the face. Depigmented macules on lip have been reported in a patient by Inamdar et al. [7] Peeling of the skin over palms soles and face was seen in 10.66% of patients in our series. Even though peeling of palms was reported by Inamdar et al. [7] in a single patient, involvement of the face was seen in our case series. Three patients had desquamation of skin over the face alone. This is probably hitherto not reported. Exacerbations of the pre-existing dermatoses have also been reported. In our case series, two patients had exacerbation of psoriasis. These exacerbations may be attributed either to the disease itself or due to the various medications especially non-steroidal anti-inflammatory drugs (NSAIDs) administered for the CF. Similar findings were also reported by Inamdar et al. [7] Other cutaneous manifestation seen in CF patients in our series included vesiculobullous eruption, pedel edema, urticaria, non-intertriginous necrotic ulcers and scrotal dermatitis which occurred during the disease period.

Even though cutaneous manifestations of CF are seen commonly, pathogenesis is unknown. Exanthems can be attributed to viral infection as seen in other viral exanthematous fever. As hyperpigmentation is mainly restricted to sunexposed areas, it can be attributed to the effect of solar UV rays. Ulcers are attributed to viral triggered vasculitis. Hemorrhagic manifestations may be due to thrombocytopenia. [7] Desquamation of the skin over the face, palms and soles can be attributed to subsiding inflammation in these areas. In one of our patients, desquamation resulted in postinflammatory hypopigmentation on the face.

Treatment of cutaneous manifestation required only symptomatic measures as reported in our case series also. [7] As the exanthematous rashes are self-limiting, no treatment is required. However, as some of the patients complained burning and itching, topical calamine lotion and antihistamines were given. Intertriginous apthae like ulcers were treated with topical and systemic antibiotics. Pigmentation of the face was treated with sunscreens and low potent corticosteroids creams for a duration of 2 weeks only. Kojic acid cream was also added in a few patients with persistent pigmentation. Desquamation was treated with topical emollients.

 
   References Top

1.de Lamballerie X, Leroy E, Charrel RN, Ttsetsarkin K,Higgs S, Gould EA. Chikungunya virus adopts to tiger mosquitoe via evolutionary convergence: a sign of things to come? Virol J 2008;5:33.  Back to cited text no. 1
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2.Mohan A. Chikungunya fever: clinical manifestations and management. Indian J Med Res 2006;124:471-4.  Back to cited text no. 2
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3.Shah KV, Gibbs CJ Jr, Banerjee G. Virological investigation of the epidemic of haemorrhagic fever in Calcutta. Isolation of three strains of Chikungunya virus. Indian J Med Res 1964;52:676-83  Back to cited text no. 3
    
4.Bandyopadhyay D, Ghosh SK. Mucocutaneous features of chikungunya fever: a study from an outbreak in West Bengal, India. Int J Dermatol 2008;47:1148-52.   Back to cited text no. 4
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5.Ravi V. Re-emergence of chikungunya Virus in India. Indian J Med Microbial 2006;24:83-4.  Back to cited text no. 5
    
6.Chhabra M, Mittal V, Bhattacharya D, Rana U, Lal S. Chikungunya fever: a re-emergence viral infection. Indian J Med Microbiol 2008;26:5-12.  Back to cited text no. 6
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7.Inamdar AC, Palit A, Sampagavi VV, Raghunath S, Deshmukh NS. Cutaneous manifestations of chikungunya fever: observation made during a recent outbreak in South India. Int J Dermatol 2008;47:154-7  Back to cited text no. 7
    
8.Morrison JG. Chikungunya fever. Int J Dermatol 1979;18:628-9.  Back to cited text no. 8
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9.Mishra K, Rajawat V. Chikungunya induced genital ulcers. Indian J Dermatol Venereal Leprol 2008;74:383-4.  Back to cited text no. 9
    
10.Borgherini G, Poubeau P, Staikowsky F, Lory M, Le Moullec N, Becquart JP, et al. Outbreak of chikungunya on Reunion Island: early clinical and laboratory features in 157 adults patients. Clin Infec Dis 2007;44:1401-7.  Back to cited text no. 10
    
11.Thomas EA, John M, Bhatia A. Cutaneous manifestation of dengue viral infection in Punjab. Int J Dermatol 2007;46:715-9.  Back to cited text no. 11
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    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2]

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