Date Published: March 11, 2015
Publisher: Public Library of Science
Author(s): Emilie Javelle, Anne Ribera, Isabelle Degasne, Bernard-Alex Gaüzère, Catherine Marimoutou, Fabrice Simon, Claudia Munoz-Zanzi. http://doi.org/10.1371/journal.pntd.0003603
Abstract: BackgroundSince 2003, the tropical arthritogenic chikungunya (CHIK) virus has become an increasingly medical and economic burden in affected areas as it can often result in long-term disabilities. The clinical spectrum of post-CHIK (pCHIK) rheumatic disorders is wide. Evidence-based recommendations are needed to help physicians manage the treatment of afflicted patients.Patients and methodsWe conducted a 6-year case series retrospective study in Reunion Island of patients referred to a rheumatologist due to continuous rheumatic or musculoskeletal pains that persisted following CHIK infection. These various disorders were documented in terms of their clinical and therapeutic courses. Post-CHIK de novo chronic inflammatory rheumatisms (CIRs) were identified according to validated criteria.ResultsWe reviewed 159 patient medical files. Ninety-four patients (59%) who were free of any articular disorder prior to CHIK met the CIR criteria: rheumatoid arthritis (n=40), spondyloarthritis (n=33), undifferentiated polyarthritis (n=21). Bone lesions detectable by radiography occurred in half of the patients (median time: 3.5 years pCHIK). A positive therapeutic response was achieved in 54 out of the 72 patients (75%) who were treated with methotrexate (MTX). Twelve out of the 92 patients (13%) received immunomodulatory biologic agents due to failure of contra-indication of MTX treatment. Other patients mainly presented with mechanical shoulder or knee disorders, bilateral distal polyarthralgia that was frequently associated with oedema at the extremities and tunnel syndromes. These pCHIK musculoskeletal disorders (MSDs) were managed with pain-killers, local and/or general anti-inflammatory drugs, and physiotherapy.ConclusionRheumatologists in Reunion Island managed CHIK rheumatic disorders in a pragmatic manner following the outbreak in 2006. This retrospective study describes the common mechanical and inflammatory pCHIK disorders. We provide a diagnostic and therapeutic algorithm to help physicians deal with chronic patients, and to limit both functional and economic impacts. The therapeutic indication of MTX in pCHIK CIR could be approved in future efficacy trials.
Partial Text: Fifty years after its first tropical description in the Newala district of Tanganyika [1,2], chikungunya (CHIK) has re-emerged extensively, resulting in 1.4 to 6.5 million infected individuals between 2004 and 2014 in Africa, as well as regions within the Indian Ocean, Southeast Asia, the Pacific Islands and Europe . Its first autochthonous transmission in the intertropical Americas was identified at the end of 2013 , and six months later this turned into a large outbreak in most of the Caribbean Islands that has now reached northern South America  and the United States . Currently, this arboviral disease represents a pressing threat to public health in large areas of the American and European continents that are colonized by the primary disease vector: the Aedes mosquito [4,7].
A total of 159 patients with persistent pCHIK-RMSD were included in this study. The population was predominantly female (75%) and the median age was 51 years-old, ranging from 16 to 80 years-old. Repartition of pCHIK-RMSD is detailed in Fig. 1. Demographic characteristics and comorbidities are presented in Table 2, according to the patients’ CHIK-RMSD categories. There was no significant difference between these groups. In the entire cohort, 66% of patients reported a prolonged acute CHIK infection (fever> 10 days or symptoms> 3 weeks). The median time elapsed between CHIK infection and the first consultation with a rheumatologist was 2 years (median delay: 15.0 months for the MSD-group and 38.5 months for the CIR group) (Fig. 2); 80% of patients with pCHIK-MSD were referred within the first two years, whereas patients with pCHIK-CIR were regularly referred throughout the 6-year period, independent of the type of CIR.
Alphaviral arthritides, including CHIK, have been blamed for causing protracted illnesses . In light of the spreading of this disease, CHIK is increasingly becoming a burden on public health in endemic/epidemic areas worldwide. Considering both the incidence of CHIK disease over the last 10 years and the prevalence of symptoms persisting at least one year after the acute infection—from 4% in India and up to 66% in Italy [14,18]—the cumulative number of CHIK-infected individuals suffering from long-lasting pain and disabilities is estimated to be at least 1–2 million people. Recent studies of the long-term clinical outcome of pCHIK mostly addressed the prevalence of pCHIK-associated pain and incapacitation [12–14,18,20,21,34], but only a few detailed the clinical expression [15,16,23] and the results of treatment [25,27,30,31,40]. To date, physicians are still facing difficulties with the nosological approach to chronic patients, as they continue to seek the most efficient and non-deleterious treatments [41,42].