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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
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