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Fever and Arthritis 2

Case of arthritis: Is this Chikungunya disease or JIA after Chikungunya disease?

Tina, aged 5 years and 8 months, living in Brazil was previously healthy. She presented with high fever, cutaneous rash and polyarthritis lasting for two weeks, which raised the diagnostic suspicion of Chikungunya. Unfortunately, Chikungunya serology was not performed. During this same period, her mother and aunt, who live together with her in the same residence in a region considered endemic for Chikungunya, presented a similar clinical picture. Chikungunya was diagnosed based on IgM positivity.

Despite a regression in arthritis, the child persisted for around 4-5 months with polyarthralgia and she refused to perform usual activities, such as attending ballet classes and doing physical activity, until her clinical picture was completely normalised.

After two months with no symptoms, Tina progressed to daily episodes of fever in the evenings, accompanied by polyarthritis of large and small joints and cervical spine, morning stiffness (lasting 30 minutes) and irritability. She did not present any signs of rash, uveitis or serositis.

Laboratory findings were: Hb 9.6; Leucocytes 16,000/mm3; Platelets 950,000/mm3; ESR120mm/1st hour; CRP 280 mg/dl (normal <6); Chikungunya positive IgG and negative IgM. Non-steroidal anti-inflammatory therapy was initiated, without resolution. She was seen by a paediatric rheumatologist three months later, and showed signs of chronic synovitis in her wrists and knees. Indomethacin and methotrexate 0.5 mg/kg were introduced, then adjusted to 0.6 mg/kg/week, with excellent clinical response.

The present case suggests that Chikungunya virus infection may have functioned as a trigger for the development of JIA in a susceptible host. Much remains unknown about the clinical presentation of this infection in children and adolescents, and the role that this virus may have in chronic arthritis development. 

Further reading is suggested - Chikungunya - a re-emerging epidemic ? Rheumatol Ther (2018). https://doi.org/10.1007/s40744-018-0121-7