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НЕОБЫЧНЫЙ СЛУЧАЙ ВИРУСНОГО МИОЗИТА: ЛИХОРАДКА ЧИКУНГУНЬЯ, ИМИТИРУЮЩАЯ ОСТРЫЙ
ИНСУЛЬТ (ГЕМОРРАГИЧЕСКИЙ ИНСУЛЬТ)
А.Н. ВЕНКАТЕШ, Б. САРВЕШ
Клиники Аполло, Бенгалур, Индия
Введение: Вирус Чикунгунья, принадлежащий роду арбовирусов и семейству тогавирусов, вызывает артропонозную самолимитирующую лихорадку. Неврологические осложнения наблюдаются редко.
Представлен клинический случай пациентки с лихорадкой Чикунгунья, которая поступила с транзитор-ными неврологическими осложнениями, имитирующими геморрагический инсульт. У больной в острой фазе развился миозит, который сохранялся до реконвалесценции.
Цель: Данный случай из практики представлен с целью информирования врачей экстренной медицинской помощи о вероятности развития неврологических осложнений и клиническими проявлениями лихорадки Чикунгунья, которая может имитировать внутричерепное кровоизлияние. Также обсуждаются различные виды неврологических осложнений при Чикунгунья и чем она отличается от лихорадки Денге, хотя оба заболевания имеют единый этиологический фактор - вирус Aedes.
Наблюдение: 64-летняя женщина, страдающая гипертонической болезнью и псориазом, обратилась в отделение неотложной помощи многопрофильной больницы с высокой температурой, прогрессирующим нарушением речи, болью в нижних конечностях, последующей ригидностью всего тела и потерей моторной функции нижних конечностей продолжительностью один день. Бригадой скорой медицинской помощи, вызванной родственниками, доставлена в отделение экстренной медицинской помощи госпиталя.
AN UNUSUAL CASE OF VIRAL MYOSITIS: CHIKUNGUNYA MASQUERADING ACUTE STROKE
(INTRACRANIAL HAEMORRHAGE)
A.N. VENKATESH, B. SARVESH
Apollo Hospitals, Bengaluru, India
Introduction: The Chikungunya virus belonging to genus alphavirus and family togaviridae causes an arthropod-borne self-limiting febrile illness. Neurological complications are infrequent.
We report here a patient with Chikungunya fever who presented with transient neurological complications mimicking stroke and developed myositis during the acute phase, which persists into convalescent period.
Objective: The case report is intended to create awareness among emergency medicine physicians of the rare neurological complications and clinical presentation of Chikungunya virus that may imitate intracranial haemorrhage. It further discusses the various forms of neurological complications seen in Chikungunya and how the disease differs from Dengue although the two conditions share a common etiologic agent namely Aedes virus.
Observation: A 64 old year woman with a known case of HTN and psoriasis, presented to the emergency department of a tertiary clinic presenting with high grade fever, progressive slurring of speech, lower limb pain and subsequent whole body rigidity and loss of motor response in lower limbs of one day duration. The patient was attended by the hospital's emergency medical staff in response to the ambulance call made by patient's family.
УДК: 616.74-002-022:616.91:616.831-005.1
On initial clinical evaluation done at patient's residence by an emergency medicine physician patient was found to be aphasic with neck rigidity and spasticity in all four lower limbs with lower limbs more spastic than upper limbs. Patient was febrile with generalized erythema particularly over the joint areas and old psoriatic lesions. The patient's blood pressure was recorded as 150/100. The patient was reported to have had 2 episodes of vomiting since morning and been experiencing fever and low back and leg pain for 2 days. Patient had decreased level of consciousness and was responding to simple verbal commands through facial gestures without any limb response. The patient was shifted to hospital in an ambulance.
On further evaluation in the emergency room the patient was maintaining saturation on room air, not following verbal commands, had aphasia, trismus, hypereflexia and spasticity in lower limbs with extensor plantar in left limb
and mute plantar in right limb. The power was 0/5 in both lower limbs and 2/5 in upper limbs.
A clinical possibility of intracranial haemorrhage was kept requiring emergent attention and a CT brain plain study was done immediately. However, it did not reveal any acute bleeding or infarction. The patient was transferred to ICU for further treatment. In the meantime patient was initiated on i.v. Monocef along with supportive treatment and was extensively worked up for fever. However, the blood reports showed normal leucocyte counts. The blood cultures and urine routine and cultures were subsequently found to be sterile.
Patient showed a dramatic recovery from her initial neurological state with disappearance of neck rigidity and spasticity in her limbs along with improvement in her consciousness level. But the serial serum CPK showed a rising trend with the highest level being 4,524 on Day
Необычный Случай Вирусного Миозита: Лихорадка Чикунгунья, Имитирующая Острый Инсульт
(Геморрагический Инсульт)
3 of hospitalization (from 323 on Day 1) in addition to a progressive thrombocytopenia. LP-CSF analysis done on Day 2 did not suggest any signs of infection.
Serological studies were positive for Chikungunya viral RNA by RT-PCR while connective tissue and vasculitic profile screening (ANA, dsDNA, cANCA, pANCA), Dengue NS1 antigen and IgM ELISA, MPQBC, leptospirosis IgM ELISA, ELISA for HIV I & II, HBsAg and anti-HCV were all negative. EEG performed on the patient did not reveal any specific information.
Discussion and conclusion: Chikungunya fever is mostly a benign self-limiting febrile illness. Though the neurological complications have been known since 1960s they are infrequent. In a study done by Chandak et al and published by Neurological Society of India the following neurological complications of Chikungunya virus were studied and tabulated as below [2]
The same study also showed that CT brain plain was normal in 20 patients with encephalitis and EEG did not reveal any specific information in all encephalitic patients.
Clinical manifestations No. of patients %
Impaired level 6 22.22
of consciousness
Abnormal behavior 16 59.25
Convulsions 3 1 1.11
Cranial nerve involvement 1 3.70
Extrapyramidal features 6 22.22
Meningeal irritations 2 7.40
Features of neuropathy 2 7.40
Features of myeloneuropathy 4 14.81
As per guidelines issued by National Institute of Communicable serum sample in acute or convalescent stage can also be used as Disease, presence of virus-specific IgM antibodies in single a confirmatory test for chikungunya in appropriate settings [2].
Diagnostic criteria for Chiiungunva fever Suspected case
A patient prelims with acme onset of fever usually nidi chilkrigars. winch lasts for 3-5 days with multiple joint pans'swelling of extremities that ma}' continue for weeks to months Probable case
Asuspected cxe (see above) with any one of the following: History of travel or residence in areas reporting outbreaks Ability to exclude malaria, dengue and any ochff known cause far fever withjoint pains Confirmed case
Any patient who meets coe or more of the following findings irrespective of the clinical presentation Virus isolation in cell culture or animal inoculations from acute phase sera Presence ofvual RNA in acute phase saa by KT-PCR
Presaice ofvirus-speciSc IgM antibodies in single serum sample in acute or convalescent stage Fourfold increase in virus-specific IgG antibody titer in samples collected at least three weeks apart
RNA: Ribonucleic acid; RT-PC R: Reverse transcription polymerase chain reaction: IgM. Immunoglobulin M: IgG. Immunoglobulin G
A study done by Mohan A et al published the diagnostic criteria for Chikungunya fever which are stated as above [8].
Another study conducted by Priscilla Karen de Oliveira Sa et al and published in March 2017 there were four cases of Chikungunya with severe neurologic complications and fatalities reported. One of these four cases was found to have similar presentation to the case study being presented by our team. That particular case is being further described here.
"A 51-year-old female farmer with diabetes was admitted with complaints of sudden lumbosacral pain in the previous 2 days, followed by loss of bowel control; 15-day history of fever, arthralgia, and skin rash also reported. At admission, she was conscious, oriented, and breathing spontaneously, but also sleepy and febrile. She presented with tetraparesis and stiff neck, without signs of joint inflammation. Cardiac and respiratory auscultation was unaltered and her blood pressure and blood glucose test were normal. A complete
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Вестник экстренной медицины, 2019, XII (4)
А.Н. Венкатеш, Б. Сарвеш
blood count (CBC) and cerebrospinal fluid (CSF) analysis were obtained by lumbar puncture. An (HIV) ELISA was negative, as were blood and CSF cultures. A CT scan of both the thoracic and lumbosacral spine was performed which showed a slight thickening of the thoracic segment of the spinal cord. Broad spectrum antibiotic therapy was started.
In serum samples, IgM (Elisa) was negative for dengue and positive for CHIKV. She developed lethargy and respiratory difficulties, and oxygen therapy with a reservoir bag was started. The patient did not respond well to supportive care measures and, 38 hours after hospital admission, she went into CRA and died [9]."
The above table compares 3 cases where the patient developed neurologic complications with either normal CSF or normal CT brain study. All the three cases also tested negative for Dengue but positive for Chikungunya [9].
This case report emphasizes the fact that Chikungunya infection which is considered a benign illness should be considered as a possible etiology while evaluating patients with spastic quadriplegia and acute exptrapyramidal features more so in patients with a history of febrile illness with rheumatological and psoriatic manifestations. Also patients with chikungunya infection should be followed up for possible neurological complications. Unlike Dengue, it causes long term arthralgia and arthritis. [4-7,9].
REFERENCES
1. Choudhary N., Makhija P., Puri V., Khwaja G.A., Duggal A. An unusual case of myelitis with myositis. JCDR 2016;10(5): OD19.
2. Chandak N.H., Kashyap R.S., Kabra D., Karandikar P., Saha S.S., Morey S.H. et al. Neurological complications of Chikungunya virus infection. Neurol India 2009; 57: 177-180.
3. National Institute of Communicable Disease, New Delhi. Chikungunya fever. CD Alert 2006; 10: 6-8.
4. Rampal Sharda M., Meena H. Neurological complications
in Chikungunya fever. J Assoc Physicians India 2007; 55: 765-769.
5. Rajapakse S., Rodrigo C., Rajapakse A. Atypical manifestations of chikungunya infection. Transactions of the Royal Society of Tropical Medicine and Hygiene 2010; 104: 89-96.
6. Ludlow M., Kortekaas J., Herden C., Hoffmann B., Tappe
D., Trebst C. et al. Neurotropic virus infections as the cause of immediate and delayed neuropathology. Acta Neuropathol 2015; 131(2): 159-184.
7. Tandale B.V., Sathe P.S., Arankalle V.A., Wadia R.S., Kulkarni R., Shah S.V. et al. Systemic involvements and fatalities during Chikungunya epidemic in India, 2006. J Clin Virol 2009; 46(2): 145-149.
8. Mohan A., Kiran D.H., Manohar I.C., Kumar D.P. Epidemiology, clinical manifestations, and diagnosis of Chikungunya fever: lessons learned from the re-emerging epidemic. Indian J Dermatol 2010; 55(1): 54.
9. Sá P.K., Nunes M.D., Leite I.R., Campelo M.D., Leäo C.F., Souza J.R., Castellano L.R., Fernandes A.I. Chikungunya virus infection with severe neurologic manifestations: report of four fatal cases. Rev Soc Bras Med Trop 2017; 50(2): 265-268.
Необычный случай вирусного миозита: лихорадка Чикунгунья, имитирующая острый инсульт
(геморрагический инсульт)
ВИРУСЛИ МИОЗИТНИНГ НООДАТИЙ НАМОЁН БУЛИШИ: УТКИР (ГЕМОРРАГИК) ИНСУЛЬТНИ ИМИТАЦИЯ К,ИЛУВЧИ ЧИКУНГУНЬЯ ИСИТМАСИ
А.Н. ВЕНКАТЕШ, Б. САРВЕШ
Аполло клиникалари, Бангалор, Х,индистон
Муцаддима: Арбовируслар туркумига ва тогавируслар оиласига мансуб булган Чикунгунья вируси узини узи чегараловчи антропоноз иситмани ча^иради. Неврологик асоратлар камдан-кам долатларда кузатила-ди. Ма^олада геморрагик инсультни имитация ^илувчи неврологик асоратлари булган Чикунгунья иситмаси булган бемор аёл билан богли^ клиник долат ёритилган. Хасталикнинг уткир бос^ичида миозит ривожланган ва у реконвалесценция давригача са^ланиб турган.
Мацсад: Ушбу клиник кузатув шошилинч тиббий ёрдам шифокорларини геморрагик инсультни имитация ^илувчи Чикунгунья иситмасида кузатиладиган неврологик асоратлар ва касалликнинг клиник куринишлари билан таништириш ма^садида келтирилган. Шунингдек, Чикунгуньяга хос турли хил неврологик асоратлар ва Чикунгунья каби Aedes вируси о^ибатида юзага келувчи Денге иситмасидан фар^ли томонлари мудокама ^илинган.
Кузатув: Гипертония касаллиги ва псориази булган 64 ёшли аёл куп тармо^ли шифохонанинг шошилинч тиббий ёрдам булимига ю^ори тана дарорати, нут^нинг кучайиб борувчи бузилиши, оё^лардаги огри^лар ва бу огри^ларнинг кейинчалик бутун тананинг ригидлигига дамда оё^лар даракатчанлигининг йу^олишига утиши каби охирги бир кун ичида юзага келган шикоятлар билан мурожаат ^илган. Беморнинг ^ариндошлари томонидан ча^ирилган тез тиббий ёрдам бригадаси томонидан шифохонанинг шошилинч тиббий ёрдам булимига келтирилган.
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Вестник экстренной медицины, 2019, XII (4)
