Chikungunya Arthritis: Implications of Acute and Chronic Inflammation Mechanisms on Disease Management

Chronic Chikungunya Arthritis and Rheumatoid Arthritis: What They Have in Common

Chikungunya virus (CHIKV) is a single-stranded RNA virus belonging to the family Togaviridae and genus Alphavirus that causes an acute febrile illness, chikungunya fever, which is transmitted to humans by Aedes species mosquitoes. During acute illness, patients have high fever, polyarthralgias or polyarthritis, maculopapular rash, headache, and myalgia that lasts for days to weeks. Following resolution of acute infection, a significant proportion of patients develop chronic chikungunya arthritis that can resemble rheumatoid arthritis. In this review, we first consider the historical background of infectious causes of inflammatory arthritis, and then the pathogenic and clinical manifestations of chronic chikungunya arthritis as a rheumatoid arthritis mimic. We believe that chronic chikungunya arthritis may be a postinfectious inflammatory process, and that an understanding of the parallels and differences between chronic chikungunya arthritis and rheumatoid arthritis may offer insights into better diagnosis and treatment of both diseases.

[Epidemic and emerging prone-infectious diseases: Lessons learned and ways forward]

Africa along side with south-east Asia are the epicentres of emerging and epidemic prone-infectious diseases and megacity biosecurity threat scenarios. Massive mobility and reluctance in the populations exposed to epidemic and emerging prone-infectious diseases coupled by a weak health system made disease alert and control measures difficult to implement. The investigation of virus detection and persistence in semen across a range of emerging viruses is useful for clinical and public health reasons, in particular for viruses that lead to high mortality or morbidity rates or to epidemics. Innovating built facility to safely treat patients with highly pathogenic infectious diseases is urgently need, not only to prevent the spread of infection from patients to healthcare workers but also to offer provision of relatively invasive organ support, whenever considered appropriate, without posing additional risk to staff. Despite multiple challenges, the need to conduct research during epidemics is inevitable, and candidate products must continue undergoing rigorous trials. Preparedness including management of complex humanitarian crises with community distrust is a cornerstone in response to high consequence emerging infectious disease outbreaks and imposes strengthening of the public health response infrastructure and emergency outbreak systems in high-risk regions.

Pathogenic Th1 responses in CHIKV-induced inflammation and their modulation upon Plasmodium parasites co-infection

The induction of polyarthritis and polyarthralgia is a hallmark of arthritogenic alphavirus infections, with an exceptionally higher morbidity observed with chikungunya virus (CHIKV). While the mechanisms underlying these incapacitating acute symptoms remain partially understood, the progression to chronic conditions in some cases remains unanswered. The highly pro‐inflammatory nature of alphavirus disease has suggested the involvement of virus‐specific, joint‐infiltrating Th1 cells as one of the main pathogenic mediators of CHIKV‐induced joint pathologies. This review summarizes the role of cell‐mediated immune responses in CHIKV pathogenesis, with a specific focus on pro‐inflammatory Th1 responses in the development of CHIKV joint inflammation. Furthermore, due to the explosive nature of arthritogenic alphavirus outbreaks and their recent expansion across the world, co‐infections with other highly prevalent pathogens such as malaria are likely to occur but the pathological outcomes of such interactions in humans are unknown. This review will also discuss the potential impact of malaria co‐infections on CHIKV pathogenesis and their relevance in alphavirus control programs in endemic areas.

Chikungunya chronic disease: a systematic review and meta-analysis

Background

Chikungunya is a mosquito-borne disease caused by an arthritogenic alphavirus, with four genotypes: East Central South African (ECSA), West African, ECSA-diverged or Indian Ocean Lineage (IOL) and Asian lineage. Overall, the disease is self-limited; however, in some patients, joint pain and other non-specific symptoms can last for months or years. This systematic review and meta-analysis aims to estimate the proportion of people that self-report chikungunya-related chronic non-specific symptoms.

Methods

Medline, EMBASE, Global Health Library and Scopus were searched for articles published before March 2017. Case-control, cohort, cross-sectional, clinical trials studies and outcome-independent case series were eligible. It was estimated that the proportion of patients who did not recover, by virus genotype, and by the time between disease onset and assessment of chronic symptoms.

Results

A total of 38 studies were included in the review and 34 in the meta-analysis. Of 6532 chikungunya patients, 3157 did not recover fully after 3 months. The overall no recovery rate associated with chikungunya was 43% (95% CI, 35-52%); Inter-genotype group heterogeneity was observed, the highest prevalence in the ECSA-diverged genotype: 50% (95% CI; 40-60%), followed by the Asian lineage genotype: 36% (95% CI; 20-52%). After 12 months follow-up, the overall no-recovery rate was 21% (95% CI; 19-22%).

Conclusion

The evidence suggests that the prevalence of chronic discomfort associated with chikungunya illness varies by virus lineage. The proportion of people that do not fully recovered after chikungunya was high and, therefore, health authorities must prepare to treat patients with symptoms of long-lasting chikungunya adequately addressing the physical, psychological and social needs.

Distinguishing patients with laboratory-confirmed chikungunya from dengue and other acute febrile illnesses, Puerto Rico, 2012-2015

Chikungunya, a mosquito-borne viral, acute febrile illness (AFI) is associated with polyarthralgia and polyarthritis. Differentiation from other AFI is difficult due to the non-specific presentation and limited availability of diagnostics. This 3-year study identified independent clinical predictors by day post-illness onset (DPO) at presentation and age-group that distinguish chikungunya cases from two groups: other AFI and dengue. Specimens collected from participants with fever ≤7 days were tested for chikungunya, dengue viruses 1-4, and 20 other pathogens. Of 8,996 participants, 18.2% had chikungunya, and 10.8% had dengue. Chikungunya cases were more likely than other groups to be older, report a chronic condition, and present <3 DPO. Regardless of timing of presentation, significant positive predictors for chikungunya versus other AFI were: joint pain, muscle, bone or back pain, skin rash, and red conjunctiva; with dengue as the comparator, red swollen joints (arthritis), joint pain, skin rash, any bleeding, and irritability were predictors. Chikungunya cases were less likely than AFI and dengue to present with thrombocytopenia, signs of poor circulation, diarrhea, headache, and cough. Among participants presenting <3 DPO, predictors for chikungunya versus other AFI included: joint pain, skin rash, and muscle, bone or back pain, and absence of thrombocytopenia, poor circulation and respiratory or gastrointestinal symptoms; when the comparator was dengue, joint pain and arthritis, and absence of thrombocytopenia, leukopenia, and nausea were early predictors. Among all groups presenting 3-5 DPO, pruritic skin became a predictor for chikungunya, joint, muscle, bone or back pain were no longer predictive, while arthritis became predictive in all age-groups. Absence of thrombocytopenia was a significant predictor regardless of DPO or comparison group. This study identified robust clinical indicators such as joint pain, skin rash and absence of thrombocytopenia that can allow early identification of and accurate differentiation between patients with chikungunya and other common causes of AFI.

The Clinical Features, Pathogenesis and Methotrexate Therapy of Chronic Chikungunya Arthritis

Chikungunya fever (CHIKF) is an emerging viral infection that has spread widely, along with its Aedes vectors, throughout the tropics and beyond, causing explosive epidemics of acute illness and persistent disabling arthritis. The rheumatic symptoms associated with chikungunya virus (CHIKV) infection include polyarthralgia, polyarthritis, morning stiffness, joint edema, and erythema. Chronic CHIK arthritis (CCA) often causes severe pain and associated disability. The pathogenesis of CCA is not well understood. Proposed hypotheses include the persistence of a low level of replicating virus in the joints, the persistence of viral RNA in the synovium, and the induction of autoimmunity. In this review, we describe the main hypotheses of CCA pathogenesis, some of which support methotrexate (MTX) treatment which has been shown to be effective in preliminary studies in CCA.

Chikungunya virus infection in Indonesia: a systematic review and evolutionary analysis

Background

Despite the high number of chikungunya cases in Indonesia in recent years, comprehensive epidemiological data are lacking. The systematic review was undertaken to provide data on incidence, the seroprevalence of anti-Chikungunya virus (CHIKV) IgM and IgG antibodies, mortality, the genotypes of circulating CHIKV and travel-related cases of chikungunya in the country. In addition, a phylogenetic and evolutionary analysis of Indonesian CHIKV was conducted.

Methods

A systematic review was conducted to identify eligible studies from EMBASE, MEDLINE, PubMed and Web of Science as of October 16th 2017. Studies describing the incidence, seroprevalence of IgM and IgG, mortality, genotypes and travel-associated chikungunya were systematically reviewed. The maximum likelihood phylogenetic and evolutionary rate was estimated using Randomized Axelerated Maximum Likelihood (RAxML), and the Bayesian Markov chain Monte Carlo (MCMC) method identified the Time to Most Recent Common Ancestors (TMRCA) of Indonesian CHIKV. The systematic review was registered in the PROSPERO database (CRD42017078205).

Results

Chikungunya incidence ranged between 0.16-36.2 cases per 100,000 person-year. Overall, the median seroprevalence of anti-CHIKV IgM antibodies in both outbreak and non-outbreak scenarios was 13.3% (17.7 and 7.3% for outbreak and non-outbreak events, respectively). The median seroprevalence of IgG antibodies in both outbreak and non-outbreak settings was 18.5% (range 0.0–73.1%). There were 130 Indonesian CHIKV sequences available, of which 120 (92.3%) were of the Asian genotype and 10 (7.7%) belonged to the East/Central/South African (ECSA) genotype. The ECSA genotype was first isolated in Indonesia in 2008 and was continually sampled until 2011. All ECSA viruses sampled in Indonesia appear to be closely related to viruses that caused massive outbreaks in Southeast Asia countries during the same period. Massive nationwide chikungunya outbreaks in Indonesia were reported during 2009–2010 with a total of 137,655 cases. Our spatio-temporal, phylogenetic and evolutionary data suggest that these outbreaks were likely associated with the introduction of the ECSA genotype of CHIKV to Indonesia.

Conclusions

Although no deaths have been recorded, the seroprevalence of anti-CHIKV IgM and IgG in the Indonesian population have been relatively high in recent years following re-emergence in early 2001. There is sufficient evidence to suggest that the introduction of ECSA into Indonesia was likely associated with massive chikungunya outbreaks during 2009–2010.

Electronic supplementary material

The online version of this article (10.1186/s12879-019-3857-y) contains supplementary material, which is available to authorized users.

Pain, balance, grip strength and gait parameters of older adults with and without post-chikungunya chronic arthralgia

OBJECTIVE

To compare the levels of pain, grip strength, balance and gait in older adults with and without post-Chikungunya chronic arthralgia (PCCA).

METHODS

Sixty-two older adults, 30 with and 32 without PCCA participated in the study. Pain level was assessed using a Visual Analogue Scale (VAS). Gait during a 10-m walk was assessed using inertial sensors. Semi-static balance was assessed during an eyes-closed bipedal balance test on a force platform, and grip strength was assessed using a hand dynamometer.

RESULTS

Participants with PCCA presented severe levels of pain (VAS > 7.5), poorer balance, lower grip strength, walked slower, with lower cadence and stride length and higher stride time and stride length variability than participants without PCCA (P < 0.001 for all variables).

CONCLUSIONS

Older adults with PCCA had high levels of pain, impaired balance and gait and lower grip strength compared to older adults without PCCA.