Chikungunya in a Neonate

Presenter: Cherry May V. Villar, M.D. First Year Resident

Adviser: Renee Joy P. Neri, M.D. Ambulatory Pediatrics, Consultant

Objectives

• To present a case of Chikungunya in a neonate

• To discuss the epidemiology, etiology, pathogenesis, differential diagnosis, diagnosis, management, recommendations, prevention and prognosis of Chikungunya infection especially in a neonate

General Data:

• Z.D.

• 16 day old, male

• Filipino, Catholic

• Meycauyan, Bulacan

Informant: mother

Reliability: 90%

Chief complaint: fever

History of Present Illness• Born to 29 year old G2P2 (2002) non smoker, non

alcoholic beverage drinker mother• Pre natal check up started at 1 month AOG with an OB-

GYNE• Known hyperthyroid but repeat thyroid function test were

of normal results, hence medications were discontinued• Ancillaries:

Test for Hepatitis B antigen -negative.

Ultrasound (3rd, 6th, 8th months age of gestations) - normal

• No exposure to radiation and teratogens. • Took multivitamins throughout the course of pregnancy.

vaccinated with Flu and tetanus toxoid during the first trimester of pregnancy.

• (+) possible Chikungunya fever among their relatives within the compound

• One day prior to delivery - sudden onset of rashes described as slightly pruritic erythematous maculopapular lesions at abdominal area. Consult done with her OB-GYN. Internal examination revealed cervical dilation of 4cm, hence advised close follow up

• Few hours prior to delivery, still with rashes, the mother had undocumented fever associated with joint pains on both hands and ankles.

• PE: Internal examination revealed cervical dilatation of 5cm

A> German measles vs Chikungunya fever

P> Admission

Labour for 2 hours

• Delivered full term via normal spontaneous delivery at Meycauayan Doctors Hospital assisted by an Obstetrician.

• The patient was reported with good cry and activity• No meconium stained amniotic fluid and cord coil was

noted loosely at the neck area. No jaundice, cyanosis nor difficulty of breathing noted. Birth weight was 2850 grams. Routine newborn care rendered: Vitamin K, erythromycin eye ointment, BCG. and Hepatitis B vaccine were given.

• Meconium passage and adequate urine output was noted in less than 24 hours of life.

• Newborn screening was done and revealed normal results. Patient was then discharged after 48 hours.

• At home the patient was active, good suck, consuming 1-2 ounces of milk formula (Enfalac) every 2 to 3 hours.

• He had adequate urine output with regular bowel movement.

• On the 3rd day of life patient had low - moderate grade fever associated with erythematous maculopapular rashes on the trunk, both upper and lower extremities, jaundice on face and trunk.

• Patient was brought to a Pediatrician and was advised admission.

• Patient was admitted at Meycauayan Doctors Hospital

A>Neonatal Sepis vs Pneumonia

Hyperbilirubinemia Secondary to ABO incompatibility

P> Phototherapy , given IVIg transfusion

IV antibiotics: Ampicillin (100mkdose) and Cefotaxime (50mkdose) for 7 days.

–During the 2nd hospital stay, patient had 1 episode of jerky movement of extremities and upward rolling of eyeballs, no cyanosis duration of approximately less than 1 minute.

–Pertinent works up showed normal HGT levels, electrolytes revealing decreased calcium.

A> Acute Symptomatic seizure probably bacterial meningitis/ Viral encephalitis.

P> IV calcium and loaded and maintained with Phenobarbital x 3 days.

Cranial ultrasound , blood culture, CSF analysis - unremarkable Request for EEG, Torch assay, Chikungunya titers where made

however not done.

• (+) episodes of heart rate with irregulary irregular rhythm.

• CK-MB - revealed slight elevation

• 2D Echo showed patent Foramen Ovale

• 15LECG – first degree AV block

A>Viral Myocarditis

• Patient was then discharged after 10 days

• Final diagnosis: Myocarditis; Meningoencephalitis, resolving; Hyperbilirubinemia sec to ABO incompatibility, resolved.

• 16th day of life - recurrence of fever (Temp 38 c) associated with circumoral cyanosis and fair suck.

• Patient remained active with no other associated symptoms such as difficulty of breathing, and seizure. Patient was brought to our institution and was subsequently admitted.

Family History

(+) hypertension – paternal side

(-) DM, PTB, CA, epilepsy

Environmental History• lives in rented house inside a compound near an

industrial area in Meycauayan, Bulacan.• The house is well lit and ventilated, with 4

household members. • Water for drinking is distilled water, not boiled

prior to consumption. • Garbage is collected thrice a week,

unsegregated.• No exposure to pesticides, toxic substances and

radiation• Presence of animals in the community such as

dogs, cats, and rats.

Nutritional History• 1-2 ounces of milk formula (Enfalac) every

2 to 3 hours.

Immunization History• BCG – 1

• Hepatitis B -1

Growth & Developmental History• Lies in flexed position, head lags,

preference to human face (+) Dolls eye

Review of SystemsGeneral: (-) loss of appetite, (-) weight gain/loss, (-) decrease activity

Cutaneous: (-) active dermatosis

HEENT: (-) nasoaural discharge, (-) epistaxis

Cardiovascular: (-) cyanosis, (-) difficulty in feeding

Respiratory: (-) cough, (-) difficulty of breathing

Genitourinary: (-) decreased urine output, (-) edema of hands and feet

Endocrine: (-) hypothermia

Nervous/Behavior: (-) tremors, (-) convulsions

Musculoskeletal: (-) limitation of motion

Hematopoietic: (-) petechiae, (-) easy bruisability

Physical Examination• Asleep but arousable, not in distress

BP 80/50 CR 142

RR 36 T: 38.1 C• Wt: 2.8 kgs ( z = 0) Lt: 48cm ( z = 0)

HC: 33cm CC: 32cm AC: 31 cm (p10-25)

• HEAD: Soft, patent, anterior fontanelle, good hair distribution

• SKIN: No jaundice, warm skin, no active dermatoses

• HEENT: normocephalic, open flat anterior and posterior fontanelles,pink conjunctivae anicteric sclerae, pink moist lips and oral mucosa, no nasal or ear discharge, supple neck, no neck vein distention,

• Chest/lungs: symmetrical chest expansion, no retractions, no chest lag, clear and equal breath sounds

• Cardiovascular: adynamic precordium, regular rate, regular rhythm, PMI at 4th ICS LMCL, no murmur

• Abdomen: globular, no visible veins, normoactive bowel sounds, soft, dried non erythematous umbilical area. No palpable mass no organomegaly

• Genitalia: grossly male, descended testis bilateral, no penile discharge

• Rectum: patent anal canal

• Extremities: full pulses warm extremities, no edema

Neurologic PE• Cranial Nerves:

I: not assessed

II: pupils 2-3 mm EBRTL, (+) ROR, no hemorrhages, no papilledema

III, IV, VI: full and equal extraocular muscle movement

V: intact sensation of the face, with good masseter, temporalis tone

VII: no facial asymmetry

IX, X: good gag reflex, uvula in midline

XI: turns head side to side

XII: tongue midline, no fasciculation• Motor: moves all extremities spontaneously and equally, good tone and

bulk. • Sensory: response to tactile stimulation• Cerebellar: no nystagmus• Deep tendon reflex: +2 in all extremities• Pathologic reflexes: (+) babinski, bilateral, no clonus, no nuchal rigidity

Salient Features

• 16 day old, male• Chief complaint: fever• (+) maternal exposure to

possible Chikungunya infection

• Maternal, fever, joint pains, erythematous maculopapular rashes on the trunk, both upper and lower extremities, jaundice on face and trunk.

• Elevated bilirubin levels• Maternal BT “O” positive,

patient’s BT “A” positive• (+) seizure• Septic work up –

unremarkable• (+) irregularly irregular HR,

ECG - first degree AV block• Elevated CKMB

Differential Diagnosis

Hyperbilirubinemia secondary to ABO

incompatibilityNeonatal Sepsis

Inborn error of metabolism/Metabolic

Encephalopathy

Working Impression

Full Term, male, Neonatal Chikungunya infection

Health care associated infection

Epidemiology • Chikungunya virus (CHIKV) • mosquito-transmitted alphavirus • first isolated in Tanzania in 1952• main vectors: Aedes species.

Pathophysiology

11th to 19th Hospital day

Course in the Ward

Chikungunya Infection

“kungunyala” - "contorted posture" or "bent posture – fever, rashes and arthalgia

arbovirus belonging to the Togaviridae

• Kiamba and Maitum in Sarangani• Villareal and Daram in Western Samar• Ma. Aurora in Aurora• Sindangan in Zamboanga del Norte• Sta. Rita in Samar• Concepcion in Romblon• Santiago in Agusan del Norte• Patnongon in Antique

Chingkungunya infection during pregnancy•50% (+) symptoms•48% asymptomatic

Maternal signs and symptoms

Percentage

fever 62

Arthralgia 93

Headache 54

Edema 54

Diarrhea 12

Apthae 9.6

epistaxis 9

rash 76Source: Fritel et al.Chikungunya Virus Infection during

Pregnancy, Réunion, France, 2006

“…the time of greatest risk of transmission of Chikungunya virus from mother to fetus appears during birth if mother acquired the disease few days before delivery.

- Shetty et al. Neonatal Chikungunya – a case report. Pediatric Oncall

“…reported cases involving symptomatic newborns with chikungunya infection in the days after birth, for whom the presumed mechanism of viral transmission was direct passage from maternal blood into the fetal circulation through placental breaches during labor.- Gerardin, P. Multidisciplinary Prospective Study of Mother-to-Child Chikungunya Virus Infections on the Island of La Re´union

Chingkungunya in Neonates

Valamparampil et al. Clinical Profile of Chikungunya in Infants

signs and symptoms

Percentage

Peripheral cyanosis

75

rash 76

fever 63

Loose stools 41

edema 19.6

seizures 37

lethargy 21.42

epistaxis 9

signs and symptoms

Percentage

fever 92

Poor feeding 71.4

Rash 64

Blotchy erythema

35

seizures 35

Respiratory distress

28

edema 14

Skin desquamation

14

Haridas et al. Neonatal Chingkungunya – a case seires

Haridas et al. Neonatal Chingkungunya – a case seires

“…complications of the disease can occur, including myocarditis, ocular disease (uveitis, retinitis), hepatitis, acute renal disease, severe bulbous lesions, and neuroinvasive disease, such as meningoencephalitis, Guillain-Barré syndrome, paresis, or palsies” - Staples, J. et al. Chikungunya Fever: An Epidemiological Review of a Re-Emerging Infectious Disease. Emerging Diseases. September 2009

Diagnostics

• Viral culture – gold standard• The detection of viral nucleic acid or of infectious virus in

serum samples is useful during the initial viremic phase, at the onset of symptoms and normally for the following 5-10 days

• IFA and ELISA are rapid and sensitive techniques for detection of CHIKV-specific antibodies, and can distinguish between IgG and IgM. IgM are detectable 2-3 days after the onset of symptoms and persist for several weeks, up to 3 months to 1 year

Treatment• No specific antiviral treatment is available for chikungunya fever. • Treatment is for symptoms and can include rest, fluids, and use of

analgesics and antipyretics. • Infected people should be protected from further mosquito exposure

(staying indoors in areas with screens or under a mosquito net) during the first few days of the illness, so they do not contribute to the transmission cycle

• Chikungunya is a self limiting illness with recovery being the rule

• Few deaths have been reported• The morbidity and mortality of the disease may be avoided

by the rational use of drugs and close monitoring of all infants.

Summary:• At our present setting, there has been an emergence of Chikungunya outbreaks

confirmed by The Department of Health (DOH) in several communities in 10 towns across our country

• Chikungunya represents a substantial risk for neonates born to viremic parturients that should be taken into account by clinicians and public health authorities in the event of a chikungunya outbreak.

• Careful history taking and physical examination and high index of suspicion remains to be the key in making the diagnosis