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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Chikungunya fever is a viral infection caused by a single-stranded RNA alphavirus belonging to the <span class="elsevierStyleItalic">Togaviridae family</span>&#46; It is transmitted to humans by <span class="elsevierStyleItalic">Aedes</span> mosquitoes&#58; <span class="elsevierStyleItalic">Aedes aegypti &#40;A&#46; aegypti&#41;</span> and <span class="elsevierStyleItalic">Aedes albopictus &#40;A&#46; albopictus&#41;</span>&#46; It is endemic in Africa and Asia&#44; causing recurrent outbreaks&#46; The spread of the disease through imported cases has caused outbreaks in indigenous regions of the Indian Ocean and Europe&#44; as happened in northern Italy in 2007&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The notification&#44; in December 2013&#44; of the first indigenous cases in the territories of the Caribbean islands has alerted international authorities on the possibility of spread of the disease to the Americas&#44; a continent so far free from the disease&#46; Since then&#44; the number of reported cases has progressively increased&#46; The spread of the disease in a globalized world is causing alarm among global epidemiological health authorities&#46; Multiple European travelers come each year to the region of the Caribbean islands&#44; the current focus of the disease and may act as a vehicle to spread the disease to the European continent&#46; Suitable climatic conditions for the development of the <span class="elsevierStyleItalic">A&#46; albopictus</span> mosquito occur in the Mediterranean region of Europe favoring the colonization of this vector&#46; Their presence has been detected in various regions of Spain&#46; Therefore&#44; Chikungunya fever could become&#44; from imported cases&#44; an emerging disease in our territory&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Clinically&#44; the disease manifests itself as acute and abrupt fever&#44; rash&#44; joint pain&#47;arthritis and fatigue that causes significant functional disability&#46; The response to symptomatic treatment is slow&#44; showing a high incidence of recurrence and chronicity at the joint level&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">A severe immune response to the viral infection is responsible for rheumatic manifestations&#46; Current therapeutic resources are scarce&#46; We have no effective antiviral treatment or vaccine&#44; and response to symptomatic treatment is moderate&#46; The study of the immunopathogenesis will lead us to more appropriate therapeutic targets&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Epidemiology and Natural History</span><p id="par0025" class="elsevierStylePara elsevierViewall">Chikungunya virus &#40;CHIKV&#41; is a single-stranded RNA alphavirus belonging the <span class="elsevierStyleItalic">Togaviridae family</span>&#46; Alphaviruses are small&#44; spherical and encapsulated viruses&#44; measuring 60&#8211;70<span class="elsevierStyleHsp" style=""></span>nm in diameter&#46; Their replicative cycle is very fast&#44; about 4<span class="elsevierStyleHsp" style=""></span>h&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">The reservoir of CHIKV in its urban endemic&#47;epidemic cycle is infected human beings&#44; and transmission occurs primarily through the bite of mosquitoes of the <span class="elsevierStyleItalic">Aedes</span> genus&#58; <span class="elsevierStyleItalic">A&#46; aegypti</span> and <span class="elsevierStyleItalic">A&#46; albopictus</span>&#46; <span class="elsevierStyleItalic">A&#46; aegypti</span> is widely distributed in the urban areas of the tropics and subtropics and is responsible for human transmission in endemic areas&#46; <span class="elsevierStyleItalic">A&#46; albopictus&#44; known in Spain as &#8220;Asian tiger mosquito&#8221;&#44; is a more aggressive mosquito&#44; active throughout the day and with longer lifetime</span>&#46; <span class="elsevierStyleItalic">The use of plastic containers and climate change in developing countries have facilitated the spread of this vector&#44; expanding to other geographical areas through transport containers and tires from Asia</span>&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a><span class="elsevierStyleItalic">Environmental changes have also led to a suitable habitat for vector development in recipient countries</span>&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a><span class="elsevierStyleItalic">Moreover</span>&#44; <span class="elsevierStyleItalic">in the course of the epidemic in the Indian Ocean&#44; there was a mutation in the E1 protein &#40;A226V</span>&#41; of CHIKV&#44; conferring an evolutionary advantage in replication to the <span class="elsevierStyleItalic">A&#46; albopictus mosquito&#44; the main</span> vector involved in the epidemic&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">5</span></a> In Spain&#44; the <span class="elsevierStyleItalic">A&#46; albopictus</span> vector is present at least since 2004&#44; when it was first detected in Sant Cugat del Vall&#232;s &#40;Barcelona&#41;&#46; In late 2012&#44; the vector had established in many cities of the Mediterranean coast &#40;Girona to Murcia&#44; with the exception of Valencia&#41; and Mallorca&#44; making it impossible to rule out its circulation to areas of the Ebro Valley&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">CHIKV was first isolated in Tanzania in 1952&#46; Initially&#44; it remained limited to East Africa and Southeast Asia&#44; causing massive epidemics&#44; such as the one that occurred between 1999 and 2000 in the Democratic Republic of Congo&#44; which affected some 50 000 people&#44; and the one that in 2000&#8211;2003 occurred in Indonesia&#46; In 2004 it began a process of global expansion&#44; characterized by various epidemics affecting 5&#8211;10 million people&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> In 2004 propagation was produced&#44; from Kenya&#44; of a new virus variant &#40;A226V&#41; adapted to the <span class="elsevierStyleItalic">A&#46; albopictus vector</span>&#44; to the islands of the Indian Ocean&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">5</span></a> The epidemic in R&#233;union island &#40;2006&#8211;2007&#41; attracted worldwide interest in this disease as a result of the significant economic and social impact produced in a zone with an elevated sociosanitary development&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> From the beginning of the epidemic&#44; more than 1000 cases of imported CHIKV have been detected in European and American travelers arriving from affected areas&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Between July and September 2007&#44; 205 indigenous cases of Chikungunya fever were detected in Italy&#44; 175 confirmed&#44; constituting the first autoctonous epidemic in Europe&#46; The cases disappeared after a drop in temperature&#44; and no new cases have been recorded so far&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> In 2010&#44; 2 new cases of local transmission occurred on the southwestern coast of France&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> As for Spain&#44; since 2006&#44; several imported cases have been notified&#46; Seco Sanchez et al&#46; analyzed<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> the presence of the infection in 308 travelers with clinical manifestations of the disease who came from endemic areas&#46;PCR and culture were used for detection&#46; 29 cases were diagnosed in total&#44; 9 in travelers from the western islands of the Indian Ocean and 20 in India&#46; These cases occurred between 2006 and 2007&#44; coinciding with epidemic outbreaks in these geographical areas&#46; Confirmation of Chikungunya fever imported into Spain has promoted the adoption&#44; in 2013&#44; of a monitoring protocol designed to avoid the occurrence of cases and preventing vector settlement&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Today&#44; a new outbreak is emerging in the region of the Caribbean islands&#46; In December 2013&#44; the publication of the first indigenous cases of Chikungunya reported in America&#44; covering the territories of the Caribbean islands&#58; British Virgin Islands&#44; Guadeloupe&#44; Martinique&#44; St&#46; Barthelemy&#44; St&#46; Maarten &#40;Dutch&#41; St&#46; Martin &#40;French&#41;&#44; French Guiana&#44; Dominica&#44; Anguilla and Aruba&#44; Santo Domingo and Haiti&#44; with 130&#44;941 suspected cases and 4486 confirmed cases &#40;June 6&#44; 2014&#44; last updated by WHO&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> The disease spreads quickly and progressively&#46; The emergence of Chikungunya fever as an emerging disease in the Americas has led to the publication by the WHO &#40;24 January 2014&#41; of a series of recommendations to prevent the progression of indigenous transmission of this disease&#46;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">14&#44;15</span></a></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Clinical Manifestations</span><p id="par0050" class="elsevierStylePara elsevierViewall">The bite of an infected mosquito in humans produces manifestations of the disease in 95&#37; of cases&#46; After CHIKV infection&#44; a silent incubation period occurs lasting 2&#8211;4 days&#46; After this short period&#44; the acute period of the disease occurs abruptly&#44; coinciding with maximum viremia&#46; It occurs with high fever&#44; followed within hours by myalgia&#44; joint pain and generalized&#44; severe and disabling arthritis&#44; accompanied by headache&#44; backache and<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> maculopapular rash&#44; predominantly on the thorax&#46; Sometimes&#44; facial edema and bullous dermatitis can also appear&#44; specially in children&#46;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">16&#44;17</span></a> The acute phase reactants are normal or moderately elevated&#46; There may be leucopenia&#44; lymphopenia and thrombocytopenia&#46; Among the ophthalmologic manifestations described&#44; we found anterior uveitis&#44; retinal vasculitis with a subsequently benign course&#44; with resolution in 6&#8211;8 weeks&#46;<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">18&#44;19</span></a> Less common manifestations are myopericarditis&#44; massive toxic hepatitis and meningoencephalitis&#46; After this acute episode of 7&#8211;10 days&#44; a high percentage of patients start the chronic phase of the disease&#46; This is manifested in the form of persistent polyarthritis&#47;polyarthralgia&#44; accompanied by morning stiffness and fatigue&#44; which remains even after 3 years&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">Fetal-maternal transmission of the virus is possible&#46; Out of 35 pregnant women with confirmed disease at the time of delivery&#44; 30 transmitted the disease to infants&#44; constituting the first cases of fetomaternal transmission documented&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> Subsequently&#44; other cases have been published by various authors&#46; Likewise&#44; transmission may occur through blood transfusion&#46; This caused considerable problems for the Italian health authorities during the epidemic that affected its territory in 2007&#59; the application of the precautionary measures taken by the blood banks led to a considerable drop in blood products&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Chikungunya fever cannot be considered a serious disease in terms of mortality refers&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> Its incidence is low and&#44; for the most part&#44; occurs in patients over 65&#46; Its severity lies in the massive involvement of numerous individuals&#44; as well as the chronicity of their rheumatic manifestations&#44; which can have an important work&#44; social and economic impact on the population&#46;</p><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Rheumatic Manifestations of the Disease</span><p id="par0065" class="elsevierStylePara elsevierViewall">Although joint pain is the most typical rheumatic manifestation&#44; both in the acute and the chronic phase&#44; arthritis with marked synovitis can be objectified in both phases of the disease&#46; It presents a distal&#44; symmetrical&#44; polyarticular pattern&#44; affecting hands&#44; wrists and ankles&#46; It less commonly affects elbows&#44; knees&#44; shoulders&#44; hips and temporomandicular joints&#46; Entheseal disease&#44; heel pain and chondrosternal pain occur less frequently&#46; The prevalence of rheumatoid factor positivity in the chronic phase of the disease varies between 25 and 43&#37;&#44; with less anti-cyclic citrullinated peptide antibody positivity&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a> Another manifestation described is tenosynovitis of the fingers&#44; wrists and ankles&#44; which can be severe&#44; contributing to the onset of carpal and tarsal and ulnar tunnel syndromes&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">Chronic polyarthritis is persistent or intermittent&#44; with or without an ongoing migratory pattern and sometimes with recurrence after resolution of the initial manifestations&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a> The affected rate decreases over time&#44; being 88 to 100&#37; in the first 6 weeks&#44; reaching 12&#37; at 3&#8211;5 years&#46; As can be seen&#44; patients with chronic polyarthritis may meet criteria for rheumatoid arthritis</p><p id="par0075" class="elsevierStylePara elsevierViewall">Other symptoms that may occur in both phases of the disease&#44; and described by various working groups&#44; are axial pain&#44; present in up to 28&#8211;32&#37; of chronic phase patients&#44;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a> Raynaud&#39;s phenomenon and asthenia&#46;</p></span></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Immunopathogenesis</span><p id="par0080" class="elsevierStylePara elsevierViewall">After inoculation&#44; the CHIKV penetrates directly into subcutaneous capillaries&#44; starting immediately replication in skin cells and macrophages&#44; fibroblasts and endothelial cells&#46; After this short phase&#44; the virus is transported to nearby lymph nodes at the site of inoculation&#44; which massively infect monocytes and macrophages&#46; Thus&#44; the virus carried by these cells quickly reaches the circulatory system&#44; to spread to different locations&#44; such as muscle&#44; joints&#44; liver and brain&#46; We consider&#44; therefore&#44; monocytes&#47;macrophages as genuine Trojan horses that help spread the virus&#46; This fact explains the persistence of the disease despite the short duration of viremia&#46; The resolution of the infection involves a vigorous immune response from the host&#46; Failure of the regulatory mechanisms of this response could be due to the persistence of inflammation in synovial tissue&#44; manifested as joint pain&#47;chronic arthritis&#46; As an expression of the inflammatory activity&#44; interleukin-6 levels remain elevated in the chronic phase of the disease&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a> The theory of the persistence of CHIKV in synovial tissue used as a reservoir is consistent with findings in animal experimental model&#46; The CHIKV is detected in the joint tissue of primates 90 days after infection&#44; with obvious signs of chronic inflammation&#46;<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">28&#44;29</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">Knowing the immunopathogenesis during disease development is instrumental in understanding its clinical course&#46; The defense against CHIKV involves both innate immunity&#44; via the action of IFN &#945; as well as adaptive immunity&#44; through various proinflammatory mediators&#46;<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">30&#44;31</span></a> It is possible that the A226V mutation detected in recent epidemics confers resistance to the antiviral activity of INF &#945;&#8901;This has not yet been demonstrated in experimental studies of inhibition of viral replication&#46; Currently&#44; knowledge of the immunobiology of l CHIKV is still in its infancy&#46; Understanding the virus&#47;host interplay helps researchers develop the right conditions for disease control strategies&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Diagnosis and Monitoring</span><p id="par0090" class="elsevierStylePara elsevierViewall">The diagnosis is established&#44; first&#44; on the basis of clinical characteristics and the epidemiology of the disease&#46; Confirmation is absolutely necessary to establish the differential diagnosis with other <span class="elsevierStyleItalic">Aedes</span> mosquito borne <span class="elsevierStyleItalic">diseases</span> such as dengue&#44; endemic in the same geographic areas&#46; The microbiology laboratory must assume the responsibility to notify any finding of an imported virus in a patient who may have started a cycle of autoctonous transmission reside in an area colonized by the vector&#46; The confirmation of the results by the National Reference Laboratory is also mandatory&#44; and of crucial importance to the efforts for national and international surveillance&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">The direct demonstration of the presence of the virus in blood through the determination of viral RNA by RT-PCR or culture isolation in cell lines must be performed as early as 5&#8211;10 days from disease onset&#44; the viremia peak time&#46; CHIKV isolation&#44; in addition to its diagnostic value&#44; is useful in biological&#44; antigenic and molecular genetics research to identify and characterize new viruses&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">After the acute episode&#44; indirect serological determinations should be made&#46; Immunofluorescence and ELISA are the most rapid and sensitive techniques for the detection of specific antibodies and allow us to distinguish between IgM and IgG&#46; IgM appears within 2&#8211;3 days after infection and is maintained over 3 months&#44; rarely more than a year&#46; IgG appears soon after IgM and persists for<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">32</span></a> years&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Treatment</span><p id="par0105" class="elsevierStylePara elsevierViewall">There is currently no specific antiviral treatment or vaccine for Chikungunya fever&#46; Symptomatic treatment is our only recourse in the acute phase of the disease&#44; although the response to nonsteroidal anti-inflammatory drugs is moderate&#46; We must be cautious with the use of steroids because of the risk of reactivation of the rheumatic manifestations after tapering&#46; The use of aspirin must be avoided due to the risk of Reye syndrome&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">It has been suggested that chloroquine&#44; being capable of reducing viral replication&#44; could be effective in the prophylaxis and treatment of early stage disease&#44; although no efficacy has been demonstrated<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">33&#44;34</span></a> in the chronic phase&#46; Moreover&#44; methotrexate has been used successfully in a group of patients with chronic destructive polyarthritis &#40;ACPA&#43;&#41; after<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">35&#44;36</span></a> CHIKV infection&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">The maintenance of inflammatory activity with elevated proinflammatory cytokines is a fact in the chronic phase&#46; This opens the door to further studies of efficacy with disease modifying drugs and even biological therapy&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">A continuing lack of vaccines&#44; preventive pest control measures and protection against mosquito bites&#44; as well as early diagnosis and notification of imported cases&#44; are measures to be taken to prevent the occurrence of an outbreak&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Conclusions</span><p id="par0125" class="elsevierStylePara elsevierViewall">Chikungunya fever may become an emerging disease in Spain&#44; where the suitable climatic conditions for <span class="elsevierStyleItalic">A&#46; albopictus</span> development&#44; the vector of the disease&#44; are present&#46; At present&#44; we have already detected the presence of this mosquito in various areas of the Mediterranean basin&#44; affecting the resident population in the form of multiple stings&#46; Potentially&#44; a massive epidemic of indigenous cases with significant morbidity may be imported&#46; Its expansion to America in a globalized world is causing alarm among global epidemiological health authorities&#46; Multiple European tourists travel each year to the region of the Caribbean islands&#44; the current focus of the disease&#44; and may act as a vehicle of spread to Europe&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">Rheumatic manifestations should be known to Spanish rheumatologists&#44; which will help us to get involved with epidemiologists&#44; microbiologists and immunologists in the management and control of the disease&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Ethical disclosures</span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Protection of human and animal subjects</span><p id="par0140" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Confidentiality of data</span><p id="par0145" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Right to privacy and informed consent</span><p id="par0150" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article&#46;</p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conflict of Interest</span><p id="par0135" class="elsevierStylePara elsevierViewall">The authors have no conflict of interest to state&#46;</p></span></span>"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Chikungunya fever is a viral disease caused by an alphavirus belonging to the Togaviridae family&#44; transmitted by several species of <span class="elsevierStyleItalic">Aedes</span> mosquitoes&#58; <span class="elsevierStyleItalic">Aedes aegypti</span> and <span class="elsevierStyleItalic">Aedes albopictus &#40;A&#46; albopictus&#41;</span>&#46; It is endemic in Africa and Asia with recurrent outbreaks&#46; It is an emerging disease and cases in Europe transmitted by <span class="elsevierStyleItalic">A&#46; albopictus</span> have been established in Mediterranean areas&#46; The first autochthonous cases detected on the Caribbean islands suppose a serious threat of spreading disease to America&#44; which so far has been disease free&#46;</p><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Clinical symptoms begin abruptly with fever&#44; skin rash and polyarthritis&#46; Although mortality is low&#44; a high percentage of patients develop a chronic phase defined by persistent arthritis for months or even years&#46; A severe immune response is responsible for joint inflammation&#46; The absence of specific treatment and lack of vaccine requires detailed studies about its immunopathogenesis in order to determine the most appropriate target&#46;</p></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">La fiebre chikungunya es una enfermedad producida por un alfavirus perteneciente a la familia <span class="elsevierStyleItalic">Togaviridae</span>&#44; transmitida por miembros de diferentes especies del g&#233;nero <span class="elsevierStyleItalic">Aede</span>s&#58; <span class="elsevierStyleItalic">Aedes aegypti y Aedes albopictus &#40;A&#46; albopictus&#41;</span>&#46; Es end&#233;mica en &#193;frica y Asia&#44; ocasionando brotes epid&#233;micos recurrentes&#46; En 2007&#44; surge de forma emergente en Europa transmitida por <span class="elsevierStyleItalic">A&#46; albopictus</span>&#44; asentado en el &#225;rea mediterr&#225;nea&#46; Los primeros casos aut&#243;ctonos detectados recientemente en las islas caribe&#241;as suponen una seria amenaza de propagaci&#243;n al continente americano&#44; libre hasta el momento de la enfermedad&#46;</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Se manifiesta de forma aguda con fiebre&#44; rash cut&#225;neo y poliartritis&#46; La mortalidad es baja&#44; pero un porcentaje elevado de enfermos desarrollan una fase cr&#243;nica definida por poliartritis persistente durante meses e incluso a&#241;os&#46;</p><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Una severa reacci&#243;n inmunitaria de defensa con incremento de citocinas proinflamatorias es la responsable de la inflamaci&#243;n articular&#46; El tratamiento es sintom&#225;tico&#46; No disponemos de terapia antiviral espec&#237;fica ni vacuna preventiva&#46; Por ello&#44; debemos profundizar en el estudio de la inmunopatog&#233;nesis&#44; con el fin encontrar dianas terap&#233;uticas m&#225;s apropiadas&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Horcada ML&#44; D&#237;az-Calder&#243;n C&#44; Garrido L&#46; Fiebre chikungunya&#46; Manifestaciones reum&#225;ticas de una infecci&#243;n emergente en Europa&#46; Reumatol Clin&#46; 2015&#59;11&#58;161&#8211;164&#46;</p>"
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                        ]
                      ]
                    ]
                  ]
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                    0 => array:2 [
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                          "etal" => false
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            2 => array:3 [
              "identificador" => "bib0015"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
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                      "titulo" => "Re-emergence of Chikungunya and other scourges&#58; the role of globalization and climate change"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "G&#46; Rezza"
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                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
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            3 => array:3 [
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              "etiqueta" => "4"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Climate change effects on Chikungunya transmission in Europe&#58; geospatial analysis of vector&#39;s climatic suitability and virus&#8217; temperature requirements"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "D&#46; Fischer"
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Review Article
Chikungunya Fever. Rheumatic Manifestations of an Emerging Disease in Europe
Fiebre chikungunya. Manifestaciones reumáticas de una infección emergente en Europa
M. Loreto Horcadaa,
Corresponding author
mlhorcada@hotmail.com

Corresponding author.
, Carlos Díaz-Calderónb, Laura Garridoa
a Servicio de Reumatología, Complejo Hospitalario de Navarra, Pamplona, Navarra, Spain
b Centro Salud Tarazona, Zaragoza, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Chikungunya fever is a viral infection caused by a single-stranded RNA alphavirus belonging to the <span class="elsevierStyleItalic">Togaviridae family</span>&#46; It is transmitted to humans by <span class="elsevierStyleItalic">Aedes</span> mosquitoes&#58; <span class="elsevierStyleItalic">Aedes aegypti &#40;A&#46; aegypti&#41;</span> and <span class="elsevierStyleItalic">Aedes albopictus &#40;A&#46; albopictus&#41;</span>&#46; It is endemic in Africa and Asia&#44; causing recurrent outbreaks&#46; The spread of the disease through imported cases has caused outbreaks in indigenous regions of the Indian Ocean and Europe&#44; as happened in northern Italy in 2007&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The notification&#44; in December 2013&#44; of the first indigenous cases in the territories of the Caribbean islands has alerted international authorities on the possibility of spread of the disease to the Americas&#44; a continent so far free from the disease&#46; Since then&#44; the number of reported cases has progressively increased&#46; The spread of the disease in a globalized world is causing alarm among global epidemiological health authorities&#46; Multiple European travelers come each year to the region of the Caribbean islands&#44; the current focus of the disease and may act as a vehicle to spread the disease to the European continent&#46; Suitable climatic conditions for the development of the <span class="elsevierStyleItalic">A&#46; albopictus</span> mosquito occur in the Mediterranean region of Europe favoring the colonization of this vector&#46; Their presence has been detected in various regions of Spain&#46; Therefore&#44; Chikungunya fever could become&#44; from imported cases&#44; an emerging disease in our territory&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Clinically&#44; the disease manifests itself as acute and abrupt fever&#44; rash&#44; joint pain&#47;arthritis and fatigue that causes significant functional disability&#46; The response to symptomatic treatment is slow&#44; showing a high incidence of recurrence and chronicity at the joint level&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">A severe immune response to the viral infection is responsible for rheumatic manifestations&#46; Current therapeutic resources are scarce&#46; We have no effective antiviral treatment or vaccine&#44; and response to symptomatic treatment is moderate&#46; The study of the immunopathogenesis will lead us to more appropriate therapeutic targets&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Epidemiology and Natural History</span><p id="par0025" class="elsevierStylePara elsevierViewall">Chikungunya virus &#40;CHIKV&#41; is a single-stranded RNA alphavirus belonging the <span class="elsevierStyleItalic">Togaviridae family</span>&#46; Alphaviruses are small&#44; spherical and encapsulated viruses&#44; measuring 60&#8211;70<span class="elsevierStyleHsp" style=""></span>nm in diameter&#46; Their replicative cycle is very fast&#44; about 4<span class="elsevierStyleHsp" style=""></span>h&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">The reservoir of CHIKV in its urban endemic&#47;epidemic cycle is infected human beings&#44; and transmission occurs primarily through the bite of mosquitoes of the <span class="elsevierStyleItalic">Aedes</span> genus&#58; <span class="elsevierStyleItalic">A&#46; aegypti</span> and <span class="elsevierStyleItalic">A&#46; albopictus</span>&#46; <span class="elsevierStyleItalic">A&#46; aegypti</span> is widely distributed in the urban areas of the tropics and subtropics and is responsible for human transmission in endemic areas&#46; <span class="elsevierStyleItalic">A&#46; albopictus&#44; known in Spain as &#8220;Asian tiger mosquito&#8221;&#44; is a more aggressive mosquito&#44; active throughout the day and with longer lifetime</span>&#46; <span class="elsevierStyleItalic">The use of plastic containers and climate change in developing countries have facilitated the spread of this vector&#44; expanding to other geographical areas through transport containers and tires from Asia</span>&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a><span class="elsevierStyleItalic">Environmental changes have also led to a suitable habitat for vector development in recipient countries</span>&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a><span class="elsevierStyleItalic">Moreover</span>&#44; <span class="elsevierStyleItalic">in the course of the epidemic in the Indian Ocean&#44; there was a mutation in the E1 protein &#40;A226V</span>&#41; of CHIKV&#44; conferring an evolutionary advantage in replication to the <span class="elsevierStyleItalic">A&#46; albopictus mosquito&#44; the main</span> vector involved in the epidemic&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">5</span></a> In Spain&#44; the <span class="elsevierStyleItalic">A&#46; albopictus</span> vector is present at least since 2004&#44; when it was first detected in Sant Cugat del Vall&#232;s &#40;Barcelona&#41;&#46; In late 2012&#44; the vector had established in many cities of the Mediterranean coast &#40;Girona to Murcia&#44; with the exception of Valencia&#41; and Mallorca&#44; making it impossible to rule out its circulation to areas of the Ebro Valley&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">CHIKV was first isolated in Tanzania in 1952&#46; Initially&#44; it remained limited to East Africa and Southeast Asia&#44; causing massive epidemics&#44; such as the one that occurred between 1999 and 2000 in the Democratic Republic of Congo&#44; which affected some 50 000 people&#44; and the one that in 2000&#8211;2003 occurred in Indonesia&#46; In 2004 it began a process of global expansion&#44; characterized by various epidemics affecting 5&#8211;10 million people&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> In 2004 propagation was produced&#44; from Kenya&#44; of a new virus variant &#40;A226V&#41; adapted to the <span class="elsevierStyleItalic">A&#46; albopictus vector</span>&#44; to the islands of the Indian Ocean&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">5</span></a> The epidemic in R&#233;union island &#40;2006&#8211;2007&#41; attracted worldwide interest in this disease as a result of the significant economic and social impact produced in a zone with an elevated sociosanitary development&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> From the beginning of the epidemic&#44; more than 1000 cases of imported CHIKV have been detected in European and American travelers arriving from affected areas&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Between July and September 2007&#44; 205 indigenous cases of Chikungunya fever were detected in Italy&#44; 175 confirmed&#44; constituting the first autoctonous epidemic in Europe&#46; The cases disappeared after a drop in temperature&#44; and no new cases have been recorded so far&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> In 2010&#44; 2 new cases of local transmission occurred on the southwestern coast of France&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> As for Spain&#44; since 2006&#44; several imported cases have been notified&#46; Seco Sanchez et al&#46; analyzed<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> the presence of the infection in 308 travelers with clinical manifestations of the disease who came from endemic areas&#46;PCR and culture were used for detection&#46; 29 cases were diagnosed in total&#44; 9 in travelers from the western islands of the Indian Ocean and 20 in India&#46; These cases occurred between 2006 and 2007&#44; coinciding with epidemic outbreaks in these geographical areas&#46; Confirmation of Chikungunya fever imported into Spain has promoted the adoption&#44; in 2013&#44; of a monitoring protocol designed to avoid the occurrence of cases and preventing vector settlement&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Today&#44; a new outbreak is emerging in the region of the Caribbean islands&#46; In December 2013&#44; the publication of the first indigenous cases of Chikungunya reported in America&#44; covering the territories of the Caribbean islands&#58; British Virgin Islands&#44; Guadeloupe&#44; Martinique&#44; St&#46; Barthelemy&#44; St&#46; Maarten &#40;Dutch&#41; St&#46; Martin &#40;French&#41;&#44; French Guiana&#44; Dominica&#44; Anguilla and Aruba&#44; Santo Domingo and Haiti&#44; with 130&#44;941 suspected cases and 4486 confirmed cases &#40;June 6&#44; 2014&#44; last updated by WHO&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> The disease spreads quickly and progressively&#46; The emergence of Chikungunya fever as an emerging disease in the Americas has led to the publication by the WHO &#40;24 January 2014&#41; of a series of recommendations to prevent the progression of indigenous transmission of this disease&#46;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">14&#44;15</span></a></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Clinical Manifestations</span><p id="par0050" class="elsevierStylePara elsevierViewall">The bite of an infected mosquito in humans produces manifestations of the disease in 95&#37; of cases&#46; After CHIKV infection&#44; a silent incubation period occurs lasting 2&#8211;4 days&#46; After this short period&#44; the acute period of the disease occurs abruptly&#44; coinciding with maximum viremia&#46; It occurs with high fever&#44; followed within hours by myalgia&#44; joint pain and generalized&#44; severe and disabling arthritis&#44; accompanied by headache&#44; backache and<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> maculopapular rash&#44; predominantly on the thorax&#46; Sometimes&#44; facial edema and bullous dermatitis can also appear&#44; specially in children&#46;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">16&#44;17</span></a> The acute phase reactants are normal or moderately elevated&#46; There may be leucopenia&#44; lymphopenia and thrombocytopenia&#46; Among the ophthalmologic manifestations described&#44; we found anterior uveitis&#44; retinal vasculitis with a subsequently benign course&#44; with resolution in 6&#8211;8 weeks&#46;<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">18&#44;19</span></a> Less common manifestations are myopericarditis&#44; massive toxic hepatitis and meningoencephalitis&#46; After this acute episode of 7&#8211;10 days&#44; a high percentage of patients start the chronic phase of the disease&#46; This is manifested in the form of persistent polyarthritis&#47;polyarthralgia&#44; accompanied by morning stiffness and fatigue&#44; which remains even after 3 years&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">Fetal-maternal transmission of the virus is possible&#46; Out of 35 pregnant women with confirmed disease at the time of delivery&#44; 30 transmitted the disease to infants&#44; constituting the first cases of fetomaternal transmission documented&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> Subsequently&#44; other cases have been published by various authors&#46; Likewise&#44; transmission may occur through blood transfusion&#46; This caused considerable problems for the Italian health authorities during the epidemic that affected its territory in 2007&#59; the application of the precautionary measures taken by the blood banks led to a considerable drop in blood products&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Chikungunya fever cannot be considered a serious disease in terms of mortality refers&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> Its incidence is low and&#44; for the most part&#44; occurs in patients over 65&#46; Its severity lies in the massive involvement of numerous individuals&#44; as well as the chronicity of their rheumatic manifestations&#44; which can have an important work&#44; social and economic impact on the population&#46;</p><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Rheumatic Manifestations of the Disease</span><p id="par0065" class="elsevierStylePara elsevierViewall">Although joint pain is the most typical rheumatic manifestation&#44; both in the acute and the chronic phase&#44; arthritis with marked synovitis can be objectified in both phases of the disease&#46; It presents a distal&#44; symmetrical&#44; polyarticular pattern&#44; affecting hands&#44; wrists and ankles&#46; It less commonly affects elbows&#44; knees&#44; shoulders&#44; hips and temporomandicular joints&#46; Entheseal disease&#44; heel pain and chondrosternal pain occur less frequently&#46; The prevalence of rheumatoid factor positivity in the chronic phase of the disease varies between 25 and 43&#37;&#44; with less anti-cyclic citrullinated peptide antibody positivity&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a> Another manifestation described is tenosynovitis of the fingers&#44; wrists and ankles&#44; which can be severe&#44; contributing to the onset of carpal and tarsal and ulnar tunnel syndromes&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">Chronic polyarthritis is persistent or intermittent&#44; with or without an ongoing migratory pattern and sometimes with recurrence after resolution of the initial manifestations&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a> The affected rate decreases over time&#44; being 88 to 100&#37; in the first 6 weeks&#44; reaching 12&#37; at 3&#8211;5 years&#46; As can be seen&#44; patients with chronic polyarthritis may meet criteria for rheumatoid arthritis</p><p id="par0075" class="elsevierStylePara elsevierViewall">Other symptoms that may occur in both phases of the disease&#44; and described by various working groups&#44; are axial pain&#44; present in up to 28&#8211;32&#37; of chronic phase patients&#44;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a> Raynaud&#39;s phenomenon and asthenia&#46;</p></span></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Immunopathogenesis</span><p id="par0080" class="elsevierStylePara elsevierViewall">After inoculation&#44; the CHIKV penetrates directly into subcutaneous capillaries&#44; starting immediately replication in skin cells and macrophages&#44; fibroblasts and endothelial cells&#46; After this short phase&#44; the virus is transported to nearby lymph nodes at the site of inoculation&#44; which massively infect monocytes and macrophages&#46; Thus&#44; the virus carried by these cells quickly reaches the circulatory system&#44; to spread to different locations&#44; such as muscle&#44; joints&#44; liver and brain&#46; We consider&#44; therefore&#44; monocytes&#47;macrophages as genuine Trojan horses that help spread the virus&#46; This fact explains the persistence of the disease despite the short duration of viremia&#46; The resolution of the infection involves a vigorous immune response from the host&#46; Failure of the regulatory mechanisms of this response could be due to the persistence of inflammation in synovial tissue&#44; manifested as joint pain&#47;chronic arthritis&#46; As an expression of the inflammatory activity&#44; interleukin-6 levels remain elevated in the chronic phase of the disease&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a> The theory of the persistence of CHIKV in synovial tissue used as a reservoir is consistent with findings in animal experimental model&#46; The CHIKV is detected in the joint tissue of primates 90 days after infection&#44; with obvious signs of chronic inflammation&#46;<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">28&#44;29</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">Knowing the immunopathogenesis during disease development is instrumental in understanding its clinical course&#46; The defense against CHIKV involves both innate immunity&#44; via the action of IFN &#945; as well as adaptive immunity&#44; through various proinflammatory mediators&#46;<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">30&#44;31</span></a> It is possible that the A226V mutation detected in recent epidemics confers resistance to the antiviral activity of INF &#945;&#8901;This has not yet been demonstrated in experimental studies of inhibition of viral replication&#46; Currently&#44; knowledge of the immunobiology of l CHIKV is still in its infancy&#46; Understanding the virus&#47;host interplay helps researchers develop the right conditions for disease control strategies&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Diagnosis and Monitoring</span><p id="par0090" class="elsevierStylePara elsevierViewall">The diagnosis is established&#44; first&#44; on the basis of clinical characteristics and the epidemiology of the disease&#46; Confirmation is absolutely necessary to establish the differential diagnosis with other <span class="elsevierStyleItalic">Aedes</span> mosquito borne <span class="elsevierStyleItalic">diseases</span> such as dengue&#44; endemic in the same geographic areas&#46; The microbiology laboratory must assume the responsibility to notify any finding of an imported virus in a patient who may have started a cycle of autoctonous transmission reside in an area colonized by the vector&#46; The confirmation of the results by the National Reference Laboratory is also mandatory&#44; and of crucial importance to the efforts for national and international surveillance&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">The direct demonstration of the presence of the virus in blood through the determination of viral RNA by RT-PCR or culture isolation in cell lines must be performed as early as 5&#8211;10 days from disease onset&#44; the viremia peak time&#46; CHIKV isolation&#44; in addition to its diagnostic value&#44; is useful in biological&#44; antigenic and molecular genetics research to identify and characterize new viruses&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">After the acute episode&#44; indirect serological determinations should be made&#46; Immunofluorescence and ELISA are the most rapid and sensitive techniques for the detection of specific antibodies and allow us to distinguish between IgM and IgG&#46; IgM appears within 2&#8211;3 days after infection and is maintained over 3 months&#44; rarely more than a year&#46; IgG appears soon after IgM and persists for<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">32</span></a> years&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Treatment</span><p id="par0105" class="elsevierStylePara elsevierViewall">There is currently no specific antiviral treatment or vaccine for Chikungunya fever&#46; Symptomatic treatment is our only recourse in the acute phase of the disease&#44; although the response to nonsteroidal anti-inflammatory drugs is moderate&#46; We must be cautious with the use of steroids because of the risk of reactivation of the rheumatic manifestations after tapering&#46; The use of aspirin must be avoided due to the risk of Reye syndrome&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">It has been suggested that chloroquine&#44; being capable of reducing viral replication&#44; could be effective in the prophylaxis and treatment of early stage disease&#44; although no efficacy has been demonstrated<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">33&#44;34</span></a> in the chronic phase&#46; Moreover&#44; methotrexate has been used successfully in a group of patients with chronic destructive polyarthritis &#40;ACPA&#43;&#41; after<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">35&#44;36</span></a> CHIKV infection&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">The maintenance of inflammatory activity with elevated proinflammatory cytokines is a fact in the chronic phase&#46; This opens the door to further studies of efficacy with disease modifying drugs and even biological therapy&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">A continuing lack of vaccines&#44; preventive pest control measures and protection against mosquito bites&#44; as well as early diagnosis and notification of imported cases&#44; are measures to be taken to prevent the occurrence of an outbreak&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Conclusions</span><p id="par0125" class="elsevierStylePara elsevierViewall">Chikungunya fever may become an emerging disease in Spain&#44; where the suitable climatic conditions for <span class="elsevierStyleItalic">A&#46; albopictus</span> development&#44; the vector of the disease&#44; are present&#46; At present&#44; we have already detected the presence of this mosquito in various areas of the Mediterranean basin&#44; affecting the resident population in the form of multiple stings&#46; Potentially&#44; a massive epidemic of indigenous cases with significant morbidity may be imported&#46; Its expansion to America in a globalized world is causing alarm among global epidemiological health authorities&#46; Multiple European tourists travel each year to the region of the Caribbean islands&#44; the current focus of the disease&#44; and may act as a vehicle of spread to Europe&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">Rheumatic manifestations should be known to Spanish rheumatologists&#44; which will help us to get involved with epidemiologists&#44; microbiologists and immunologists in the management and control of the disease&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Ethical disclosures</span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Protection of human and animal subjects</span><p id="par0140" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Confidentiality of data</span><p id="par0145" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Right to privacy and informed consent</span><p id="par0150" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article&#46;</p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conflict of Interest</span><p id="par0135" class="elsevierStylePara elsevierViewall">The authors have no conflict of interest to state&#46;</p></span></span>"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Chikungunya fever is a viral disease caused by an alphavirus belonging to the Togaviridae family&#44; transmitted by several species of <span class="elsevierStyleItalic">Aedes</span> mosquitoes&#58; <span class="elsevierStyleItalic">Aedes aegypti</span> and <span class="elsevierStyleItalic">Aedes albopictus &#40;A&#46; albopictus&#41;</span>&#46; It is endemic in Africa and Asia with recurrent outbreaks&#46; It is an emerging disease and cases in Europe transmitted by <span class="elsevierStyleItalic">A&#46; albopictus</span> have been established in Mediterranean areas&#46; The first autochthonous cases detected on the Caribbean islands suppose a serious threat of spreading disease to America&#44; which so far has been disease free&#46;</p><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Clinical symptoms begin abruptly with fever&#44; skin rash and polyarthritis&#46; Although mortality is low&#44; a high percentage of patients develop a chronic phase defined by persistent arthritis for months or even years&#46; A severe immune response is responsible for joint inflammation&#46; The absence of specific treatment and lack of vaccine requires detailed studies about its immunopathogenesis in order to determine the most appropriate target&#46;</p></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">La fiebre chikungunya es una enfermedad producida por un alfavirus perteneciente a la familia <span class="elsevierStyleItalic">Togaviridae</span>&#44; transmitida por miembros de diferentes especies del g&#233;nero <span class="elsevierStyleItalic">Aede</span>s&#58; <span class="elsevierStyleItalic">Aedes aegypti y Aedes albopictus &#40;A&#46; albopictus&#41;</span>&#46; Es end&#233;mica en &#193;frica y Asia&#44; ocasionando brotes epid&#233;micos recurrentes&#46; En 2007&#44; surge de forma emergente en Europa transmitida por <span class="elsevierStyleItalic">A&#46; albopictus</span>&#44; asentado en el &#225;rea mediterr&#225;nea&#46; Los primeros casos aut&#243;ctonos detectados recientemente en las islas caribe&#241;as suponen una seria amenaza de propagaci&#243;n al continente americano&#44; libre hasta el momento de la enfermedad&#46;</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Se manifiesta de forma aguda con fiebre&#44; rash cut&#225;neo y poliartritis&#46; La mortalidad es baja&#44; pero un porcentaje elevado de enfermos desarrollan una fase cr&#243;nica definida por poliartritis persistente durante meses e incluso a&#241;os&#46;</p><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Una severa reacci&#243;n inmunitaria de defensa con incremento de citocinas proinflamatorias es la responsable de la inflamaci&#243;n articular&#46; El tratamiento es sintom&#225;tico&#46; No disponemos de terapia antiviral espec&#237;fica ni vacuna preventiva&#46; Por ello&#44; debemos profundizar en el estudio de la inmunopatog&#233;nesis&#44; con el fin encontrar dianas terap&#233;uticas m&#225;s apropiadas&#46;</p></span>"
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        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Horcada ML&#44; D&#237;az-Calder&#243;n C&#44; Garrido L&#46; Fiebre chikungunya&#46; Manifestaciones reum&#225;ticas de una infecci&#243;n emergente en Europa&#46; Reumatol Clin&#46; 2015&#59;11&#58;161&#8211;164&#46;</p>"
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                  ]
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ISSN: 21735743
Original language: English
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Idiomas
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