Chikungunya differential diagnosis

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Alejandro Lemor, M.D. [2], Alonso Alvarado, M.D. [3]

Overview

Chikunguyna must be differentiated from other diseases that present with flu like symptoms such as fever, headache, fatigue, joint aches or arthralgias, myalgias. Diseases with similar symptoms include dengue fever, influenza, measles, rubella, malaria, and yellow fever.

The differential diagnosis of chikungunya virus infection varies based on the place of residence, the travel history, and the history of exposures.
Dengue and chikungunya viruses are transmitted by the same mosquitoes (Aedes aegypti and Aedes albopictus) and have similar clinical features.
The two viruses can circulate in the same area and can cause occasional co-infections in the same patient.
Chikungunya virus infection is more likely to cause high fever, severe arthralgia, arthritis, rash, and lymphopenia, while dengue virus infection is more likely to cause neutropenia, thrombocytopenia, hemorrhage, shock, and death.
It is important to rule out dengue virus infection because proper clinical management of dengue can improve the outcome.
In addition to dengue, other considerations include leptospirosis, malaria, rickettsia, group A streptococcus, rubella, measles, parvovirus, enteroviruses, adenovirus, other alphavirus infections (e.g., Mayaro, Ross River, Barmah Forest, O’nyong’nyong, and Sindbis viruses), post-infection arthritis, and rheumatologic conditions.

Shown below is a table summarizing the typical findings of the differential diagnoses of chikungunya.


Disease	Findings
Malaria	Periodic fever and altered level of consciousness
Dengue Fever	Fever and two or more of the following: retro-orbital or ocular pain, headache, rash, myalgia, arthralgia, leucopenia, or hemorrhagic manifestations
Leptospirosis	Severe myalgia localized to calf muscles, conjunctival congestion or subconjunctival hemorrhage, with or without jaundice or oliguria History of contact with contaminated water
Alphaviral infections (Mayaro, Ross River, Barmah Forest, O’nyong nyong, and Sindbis viruses)	Similar clinical presentation as Chikunguyna Travel history and known areas of Mayaro in the Americas
Post-infectious arthritis (including rheumatic fever)	Arthritis of one or more, typically larger joints due to an infectious disease such as Chlamydia, Shigella, and gonorrhea Rheumatic fever is seen more commonly in children as migratory polyarthritis predominantly affecting large joints. Consider antistreptolysin O (ASO) titer and history of sore throat with Jones criteria for rheumatic fever.
Juvenile rheumatoid arthritis	Abrupt onset of fever and subsequent joint involvement in children
Table adapted from Preparedness and Response for Chikungunya Virus: Introduction in the Americas. PAHO © 2011.^[1]

Chikungunya should be distinguished from dengue fever, which has the potential for much poorer clinical outcomes, including death. The two diseases can occur together in the same patient.
Shock or severe hemorrhage is very rarely observed in Chikungunya.
In Chikungunya the onset of the disease is more acute and the duration of fever is much shorter.
A maculopapular rash is more frequent in Chikungunya, while petechia may occur in dengue fever.
In Chikungunya the pain is much more pronounced and localized to the joints and tendons in comparison to dengue fever in which the pain is generalized.

**Clinical and laboratory findings of chikunguyna and dengue fever**
Clinical Findings	Chikungunya	Dengue Fever
Fever (>102°F or 39°C)	+++	++
Headache	++	++
Rash	++	+
Arthralgias	+++	+/–
Myalgias	+	++
Shock	—	+/–
Bleeding dyscrasias	+/–	++
Laboratory Findings
Elevated hematocrit	—	++
Leukopenia	++	+++
Neutropenia	+	+++
Lymphopenia	+++	++
Thrombocytopenia	+	+++
Mean frequency of symptoms from studies where the two diseases were directly compared among patient seeking care; +++ = 70-100% of patients; ++ = 40-69%; + = 10-39%; +/– = <10%; — = 0%^[3]^[4]

↑ Preparedness and response for Chikungunya virus introduction in the Americas. Washington, DC: Pan American Health Organization CDC, Center for Disease Control and Prevention. 2011. ISBN 978-92-75-11632-6.
↑ Staples, J. Erin; Breiman, Robert F.; Powers, Ann M. (2009). “Chikungunya Fever: An Epidemiological Review of a Re‐Emerging Infectious Disease”. Clinical Infectious Diseases. 49 (6): 942–948. doi:10.1086/605496. ISSN 1058-4838.
↑ S. Nimmannitya, S. B. Halstead, S. N. Cohen & M. R. Margiotta (1969). “Dengue and chikungunya virus infection in man in Thailand, 1962-1964. I. Observations on hospitalized patients with hemorrhagic fever”. The American journal of tropical medicine and hygiene. 18 (6): 954–971. PMID 5355242. Unknown parameter |month= ignored (help)
↑ Patrick Hochedez, Ana Canestri, Amelie Guihot, Segolene Brichler, Francois Bricaire & Eric Caumes (2008). “Management of travelers with fever and exanthema, notably dengue and chikungunya infections”. The American journal of tropical medicine and hygiene. 78 (5): 710–713. PMID 18458301. Unknown parameter |month= ignored (help)