MRU Subacute Polyarticular Arthralgias Case Study

Subacute polyarticular arthralgias • swelling of the ankles and right knee • recenttravel to the Dominican Republic • Dx?
A 78-year-old woman with a history of anxiety and hypertension presented to our family
medicine residency practice in Massachusetts with subacute polyarticular arthralgias that
had been present for 2 months. She complained of pain and swelling of both ankles and the
right knee. She noted that her symptoms had started on a recent trip to the Dominican
Republic, where she developed generalized joint pain and a fever that lasted 1 to 2 weeks
and subsequently resolved with the lingering polyarthralgia. She denied any rash,
constitutional symptoms, photosensitivity, headaches, photophobia, or history of tick bite.
Physical examination revealed normal vital signs, notable warmth and swelling of the
bilateral ankles that was worse on the right side, and swelling of the right knee with
effusion—but no tenderness—to palpation.
Possible Diagnosis with rational explanation.
At least 3 differentials must be mentioned with rationales explanation.
T
THE PATIEN
78-year-old
woman
CASE REPORT
MPTOMS
SIGNS & SY icular
rt
acute polya
– Sub
arthralgias
the ankles
 welling of
–S
ee
and right kn
vel to the
– Recent tra
Republic
Dominican
Jeremy Golding, MD;
Jeffrey Wacks, MD
Hahnemann Family
Health Center, Worcester
Family Medicine
Residency, University of
Massachusetts Medical
School
Jeremy.Golding@
umassmemorial.org
The authors reported no
potential conflict of interest
relevant to this article.
THE CASE
A 78-year-old woman with a history of anxiety and hypertension presented to our family
medicine residency practice in Massachusetts with subacute polyarticular arthralgias that
had been present for 2 months. She complained of pain and swelling of both ankles and
the right knee. She noted that her symptoms had started on a recent trip to the Dominican
Republic, where she developed generalized joint pain and a fever that lasted 1 to 2 weeks
and subsequently resolved with the lingering polyarthralgias. She denied any rash, constitutional symptoms, photosensitivity, headaches, photophobia, or history of tick bite. Physical examination revealed normal vital signs, notable warmth and swelling of the bilateral
ankles that was worse on the right side, and swelling of the right knee with effusion—but no
tenderness—to palpation.
THE DIAGNOSIS
The patient’s labwork revealed a white blood cell count of 5900/mcL (reference range, 4500–
11,000/mcL), hemoglobin count of 12.5 g/dL (reference range, 14–17.5 g/dL), and a platelet
count of 230×103/mcL. Electrolytes and renal function were normal. She had an elevated
erythrocyte sedimentation rate of 34 mm/h (reference range, 0–20 mm/h) and a positive
antinuclear antibody (ANA) test, but no titer was reported. Anti-chikungunya IgG and IgM
antibodies were positive on enzyme-linked immunosorbent assay (ELISA) serologic testing.
DISCUSSION
Chikungunya is an infectious disease that is relatively rare in the United States. Chikungunya was rarely identified in American travelers prior to 2006, but incidence increased over
the next decade. In 2014, a total of 2811 cases were reported.1 Chikungunya is an RNA arbovirus that is transmitted by Aedes aegypti and Aedes albopictus mosquitoes and is endemic
to West Africa. Within the last 2 decades, there has been an increasing number of outbreaks
in India, Asia, Europe, and the Americas, where the highest incidence is in South America,
followed by Central America. In the United States, almost all reported cases of chikungunya
infection have been in travelers returning from endemic areas.2 The first 2 known cases of
local transmission in the United States were reported in Florida in July 2014.3 Local transmission of chikungunya is significant in that it represents the possibility of a local reservoir
for sustained transmission.
z Disease presentation. Patients will initially complain of a high fever and severe distal
polyarthralgias that usually are symmetric. The most common symptoms are polyarthralgias (87%–98% of patients), myalgias (46%–59%), and a maculopapular rash involving the
palms and soles (40%–50%).4 Other associated symptoms include headaches, photophobia,
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CASE REPORT
Chikungunya
virus is
increasingly
common in
American
travelers
returning from
tropical and
subtropical
regions.
172
and digestive symptoms. Respiratory symptoms are not present in chikungunya.5
The term chikungunya is derived from
a Kimakonde (central Bantu) word meaning “that which bends up” because of the arthralgia caused by the disease. Fever usually
lasts 3 to 7 days; polyarthralgia begins shortly
after the onset of fever.4 Frank arthritis also
may be present. Infection often exacerbates a
previously damaged or diseased joint. Acute
symptoms usually persist for 1 to 2 weeks,
but arthralgias and arthritis can persist for
months to years following resolution of the
acute disease.6 In one study of 47 patients with
acute chikungunya in Marseilles, France, the
number of patients who were symptomatic
declined from 88% to 86%, 48%, and 4% at
1, 3, 6, and 15 months, respectively.7
z The differential diagnosis includes
tropical infectious diseases (dengue, chikungunya, Zika, and leptospirosis) in patients
who have recently traveled to the tropics
and who complain of subacute polyarticular
arthralgias or arthritis; locally acquired infections associated with arthralgia/arthritis
such as Lyme disease and other tick-borne
diseases and rickettsial infections; parvovirus
B19 and other postinfectious arthritides; and
rheumatologic conditions such as systemic
lupus.
Clinical differentiation among dengue,
chikungunya, and Zika may be difficult, although persistent frank arthritis is much
more common in chikungunya than in dengue or Zika. Furthermore, conjunctivitis is
present in Zika but is absent in chikungunya.
Chikungunya also is more likely to cause high
fever, severe arthralgia, arthritis, rash, and
lymphopenia than Zika or dengue. Dengue is
more likely to cause lymphopenia and hemorrhagic consequences than is chikungunya
or Zika.8
In our patient, dengue titers were not obtained because the duration of symptoms was
thought to be more consistent with chikungunya, but testing for dengue also would have
been appropriate. If present, fever typically is
low-grade in Zika and is shorter in duration
than in chikungunya (approximately 2–3 days
vs 5–7 days).9 Coinfection with chikungunya
and Zika sometimes occurs because the same
mosquito species transmit both diseases.
z The most common test for diagnosing
acute chikungunya is ELISA serologic testing
for IgM antibodies, which develop toward the
end of the first week of infection; earlier in that
first week, serum testing for viral RNA may be
performed by polymerase chain reaction.
Treatment is largely supportive
Treatment of acute chikungunya is largely
supportive and includes anti-inflammatory
agents. To our knowledge, no antiviral agents
have been shown to be effective. Postacute
or chronic symptoms may require treatment
with glucocorticoids or other immunomodulatory medications. A 2017 literature review
of treatments for chikungunya-associated
rheumatic disorders showed evidence that
chloroquine was more effective than placebo
for chronic pain relief. Also, adding a diseasemodifying antirheumatic agent in combination with chloroquine was more effective for
controlling pain and reducing disability than
hydroxychloroquine monotherapy.10
z Our patient was treated with ibuprofen only and experienced resolution of joint
symptoms several months after the initial
presentation. A repeat ANA test 12 months
later was negative.
A 2009 review of the medical literature
revealed a single case report of chikungunya
associated with positive ANA.8 Although a
positive ANA may be associated with acute
viral infections, significantly elevated ANA
levels typically are associated with autoimmunity. Resolution of the patient’s serum
ANA 1 year later suggested that the positive
ANA was not secondary to a pre-existing
rheumatologic condition but rather a consequence of her body’s response to the chikungunya infection itself. Our case raises the
hypothesis that, at least in some cases, chikungunya somehow stimulates a temporary
autoimmune response, which may help explain why immunomodulatory medications
can be effective treatment options.
THE TAKEAWAY
Chikungunya is increasingly common in
tropical and subtropical regions. Family phy-
THE JOURNAL OF FAM ILY PRACTICE | A PR IL 2019 | VOL 68, N O 3
CASE REPORT
C O N T I N UE D FR OM PA G E 1 7 2
sicians practicing in the United States should
become familiar with the common patterns
of presentation of viruses such as chikungunya, dengue, and Zika. Obtaining a travel
history for patients presenting with arthritis
improves the differential diagnosis and may
even reveal the cause of the condition.
JFP
CORRESPONDENCE
Jeremy Golding, MD, 279 Lincoln Street, Worcester, MA
01605; Jeremy.Golding@umassmemorial.org
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