รศ พญ ศิริลั อน ันตกษณ ณัิริฐศ 24-6-2009.pdf ·...
Transcript of รศ พญ ศิริลั อน ันตกษณ ณัิริฐศ 24-6-2009.pdf ·...
รศ.พญ.ศิริลักษณ อนันตณัฐศิริสาขาวิชาโรคติดเชื้อและเวชศาสตรเขตรอน
ภาควิชาอายุรศาสตร คณะแพทยศาสตรมหาวิทยาลยัขอนแกน
ChikungunyaChikungunya virus
Arthropod-borne virus (arbovirus)Single-stranded, enveloped RNA virus genus Alphavirusfamily Togaviridae
VectorAedes spp. mosquitoes
Enzootic and Zoonotic disease
Lancet Infect Dis 2007; 7:319-27.J Gen Virol 2007; 88: 2363-2377.
Chikungunya Virus Genome
Non-structural proteins required for viral replication
Structural proteins • Cytoplasmic nucleocapsid protein• 2 major envelope surface glycoprotein (E1 & E2)• 2 small peptides (E3 & 6K)
J Gen Virol 2007; 88: 2363-2377.
J Gen Virol 2007; 88: 2363-2377.
Phylogenetic Analysis of ChikungunyaOutbreaks
J Gen Virol 2007; 88: 2363-2377.
Chikungunya transmission cycles
(A. taylori, A. africanus, A. furcifer )
(A. aegypti , A. albopictus )
African Chikungunya = rural, sylvatic cycle
Asian Chikungunya = urban, domestic cycle
J Gen Virol 2007; 88: 2363-2377
Clinical Presentations of ChikungunyaInfection
Incubation period2-10 days (usually 2-3 days)
Acute stage1-10 daysClinical triad: Fever, Rash, Rheumatic manifestations
Chronic stage5-10% of patientsSeveral weeks yearsRheumatic manifestations
Clinical Presentations of Acute Chikungunya Infection
Sign or symptoms No. of patients %Fever 296 100Joint pain 296 100Joint swelling 118 40Rash 83 28Back pain 123 42Headache 93 31Shoulder pain 57 19Retro-orbital pain 23 8Difficulty walking 17 6Polyarthritis 35 12Vomiting 12 4
Clin Infect Dis 2008; 46:1436-42.
Rash in Chikungunya Fever
Emerg Infect Dis 2006; 12:1565-7; Med Clin North Am 2008; 92: 1323-43; J Travel Med 2007; 14: 320-5.
Rheumatological Manifestations in Acute Stage of Chikungunya Fever
Weekly Epidemiol Surv Rep 2008; 39: 717-22.
Atypical Clinical Presentations of ChikungunyaFever
MyocarditisHemorrhagic manifestationsFulminant hepatitisNeurologic manifestations
MeningoencephalitisGuillain-Barré syndrome
Chronic Stage of Chikungunya Infection
Polyarthritis and tenosynovitis of wrists and
fingers
Hypertrophictenosynovitis
J Gen Virol 2007; 88: 2363-2377.
Chronic Stage of Chikungunya Infection
Bursitis
Med Clin North Am 2008; 92: 1323-43.
Chronic Stage of Chikungunya Infection
Raynaud’s phenomenonChronic swelling and stiffness of
the fingers with loss of grip strength
Med Clin North Am 2008; 92: 1323-43.
Differential Diagnosis of ChikungunyaFever
Dengue feverLeptospirosisRickettsiosesMalariaRubellaRheumatic fever
Alphaviruses causing Fever, Rash and Polyarthritis
O’Nyong Nyong virus Africa
Sindbis virus tropical Africa
Ross River virus Australia
Barmah Forest virus South Pacific
Mayaro virus South America
Clinical differences between Chikungunya and Dengue infection
Chikungunya Dengue FeverFever, asthenia Common CommonRash Days 1–4, important skin
edemaDays 3-7
Retro-orbital pain
Rare CommonMyalgia Possible Very commonPolyarthritis Very common, edematous NoneTenosynovitis Yes NoneHypotension Possible Common, days 5-
7Minor bleeding Possible CommonSecond stage •Chronic polyarthritis up to 1
year•Tenosynovitis at M2–M3•Raynaud’s syndrome at M2–M3
Fatigue up to 3 months
Med Clin North Am 2008; 92: 1323-43.
Laboratory differences between Chikungunya and Dengue infection
N (%)Laboratory finding Chikungunya
(22 cases)Dengue
(16 cases)
P
Leucopenia 8 (40) 12 (75) 0.033Neutropenia 2 (10) 13 (81) <0.001Lymphopenia 18 (90) 9 (56) 0.049Lymphocytosis 6 (30) 5 (31) NSAnemia 3 (15) 0 NSThrombocytopenia
7 (35) 14 (88) 0.002Increased ALT 13 (65) 14 (88) NSIncreased CRP 9 (64) 10 (77) NS
Am J Trop Med Hyg 2008; 78: 710-713.
Laboratory Diagnosis of Chikungunya Infection
Virus isolation RT-PCR techniqueSerologyELISA, neutralization test, hemagglutination inhibition
assay
Lancet Infect Dis 2007; 7:319-27.
RT-PCR Techniques for Diagnosis of Chikungunya Fever
Clin Infect Dis 2008; 46:1436-42.
Management of Chikungunya Infection
A non-fatal, self-limiting illness
No specific antiviral drug against chikungunya virus
Supportive careParacetamol is drug of choice for fever/pain.
Use of other analgesics/anti-inflammatory drugs if paracetamol does not provide relief; avoid aspirin, steroid
Rest during acute joint symptoms; cold compression
Mild exercise/physiotherapy are recommended in recovering persons.
Use hydroxychloroquine 200 mg or chloroquin phosphate 300 mg PO per day for 4 weeks in cases with refractory arthralgia to other drugs
Prevention and Control of Chikungunya Infection
No available vaccine for chikungunya
Patient/Community education
Minimize the vectorMinimize the vector--patient contact patient contact
Have the patient/other family members rest under bed-nets and wear full sleeves to cover extremities, preferably bright coloured clothes
Insecticide sprays
Wire-mesh/ nets on doors and windows
Prevention and Control of Chikungunya Infection
Patient/Community education
Minimizing vector populationMinimizing vector population
Remove stagnant water from all junk items lying around in the household and in the peri-domestic areas
Stagnating water in flower pots or similar containers should be changed daily or at least twice weekly.
Introduce larvivorous fish in aquaria, garden pools, etc.
Prevention and Control of Chikungunya Infection
Patient/Community educationMinimizing vector populationMinimizing vector population
Weeds and tall grasses should be cut short to minimize shady spaces where the adult insects hide and rest during hot daylight hoursDrain all water stagnating after rainsFogging and street sanitation with proper waste management in epidemic situation
แนวทางการเฝาระวังโรคไขปวดขอยุงลาย (Chikungunya)
แนวทางการเฝาระวังโรคไขปวดขอยุงลาย (Chikungunya)
แนวทางการเฝาระวังโรคไขปวดขอยุงลาย (Chikungunya)
แนวทางการเฝาระวังโรคไขปวดขอยุงลาย (Chikungunya)