Case Report
Imported Chikungunya Fever in Madrid
Fiebre chikungunya importada en Madrid
Patricia Richi Alberti
, Martina Steiner, Óscar Illera Martín, Patricia Alcocer Amores, Tatiana Cobo Ibáñez, Santiago Muñoz Fernández
Corresponding author
Hospital Universitario Infanta Sofía, San Sebastián de los Reyes, Madrid, Spain
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Until recently, because of its geographic distribution, it was considered a tropical disease. However, the virus has mutated and become adapted to a vector, <span class="elsevierStyleItalic">Aedes albopictus</span>, the tiger mosquito, that is more widely distributed than its classical vector, <span class="elsevierStyleItalic">Aedes aegypti</span>,<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> and is found in regions including the Spanish Mediterranean basin. The area of autochthonous transmission now encompasses Africa, Asia, Europe (Italy and France) and, since the epidemic involving more than 1 000 000 cases declared in the Caribbean at the end of 2013, the American continent, as well.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case Reports</span><p id="par0010" class="elsevierStylePara elsevierViewall">Between July and September 2014, 3 patients from primary care and 1 from the emergency department were referred to our rheumatology department after several weeks of arthralgia or arthritis. The epidemiologic factor that they shared was a trip to the Dominican Republic in the weeks prior to onset. All 4 developed fever, rash and musculoskeletal symptoms, which began during their stay in Santo Domingo in 3 and a few days after returning to Spain in the fourth. They presented with severe arthralgia, which was accompanied by polyarthritis suggestive of rheumatoid arthritis only in the patient of advanced age, a factor that has been related to the persistence of arthropathy.<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">3,4</span></a> The diagnosis was confirmed by serological tests. One of the patients tested negative for IgM and positive for IgG, a finding explained by the interval of over 2 months between clinical onset and the analyses. The dengue serology revealed signs of previous contact in the 3 Dominican patients. Rheumatoid factor (RF) and anti-cyclic citrullinated peptide (CCP) antibodies were negative in all the patients. In 1 case, antinuclear antibodies were positive but later became negative, a circumstance reported in numerous infections. There was no radiological evidence of joint damage. When they first came to our department, all the patients had already received a nonsteroidal anti-inflammatory drug and corticosteroids, a fact that reflects the severity of the symptoms. Only the woman with polyarthritis required maintenance of prednisone, which was tapered over several weeks. In no case did the disease last more than 4 weeks. There was 1 recurrence, with a subsequent positive response (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0015" class="elsevierStylePara elsevierViewall">Chikungunya fever presents with nonspecific clinical features, often including joint pain. The recent trip was the decisive epidemiologic factor for the diagnosis in our patients, as occurred in the 10 patients reported in Catalonia, Spain, in July 2014<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a> and the 79 cases declared up to November 2014 in the Community of Madrid (<span class="elsevierStyleItalic">Boletín de Información Epidemiológica de la Consejería de Sanidad</span> [Bulletin of Epidemiological Information of the Madrid Health Administration]). However, we must keep in mind the possibility of autochthonous transmission in zones inhabited by the tiger mosquito (in Spain, Catalonia, the Valencian Community and the Region of Murcia),<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> should an individual carrying the chikungunya virus come to these regions.</p><p id="par0020" class="elsevierStylePara elsevierViewall">All our patients tested negative for RF and anti-CCP antibodies, contrasting with previously reported rates of seropositivity of 20%-30%.<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">7,8</span></a> Their conditions resolved within a maximum of 16 weeks. However, the transition to chronic joint involvement is a well-known complication, sometimes in the form of nonspecific arthralgia, soft tissue disease or an inflammatory process suggestive of rheumatoid arthritis, spondyloarthritis or undifferentiated arthritis,<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">8–10</span></a> which have been found to respond well to treatment with synthetic or biologic disease-modifying antirheumatic drugs.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a> These are the patients that benefit the most from early referral to a rheumatology department, as occurred in our series, making it possible to take advantage of a hypothetical therapeutic window.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conclusions</span><p id="par0025" class="elsevierStylePara elsevierViewall">Chikungunya can be included in the differential diagnosis not only of travelers from regions in which the virus is endemic, but of any individual with the typical signs and symptoms living in a region where transmission is viable. As rheumatologists, we must be knowledgeable about the situation in order to contribute to controlling the possible expansion of this virus, which is a notifiable disease, and to offer patients optimal specialized care.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Ethical Disclosures</span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Protection of human and animal subjects</span><p id="par0030" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Confidentiality of data</span><p id="par0035" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Right to privacy and informed consent</span><p id="par0040" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article.</p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Funding</span><p id="par0045" class="elsevierStylePara elsevierViewall">The authors received no funding.</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Conflicts of Interest</span><p id="par0050" class="elsevierStylePara elsevierViewall">The authors declare they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:12 [ 0 => array:3 [ "identificador" => "xres824587" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec821067" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres824588" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec821066" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Case Reports" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Conclusions" ] 8 => array:3 [ "identificador" => "sec0025" "titulo" => "Ethical Disclosures" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0030" "titulo" => "Protection of human and animal subjects" ] 1 => array:2 [ "identificador" => "sec0035" "titulo" => "Confidentiality of data" ] 2 => array:2 [ "identificador" => "sec0040" "titulo" => "Right to privacy and informed consent" ] ] ] 9 => array:2 [ "identificador" => "sec0045" "titulo" => "Funding" ] 10 => array:2 [ "identificador" => "sec0050" "titulo" => "Conflicts of Interest" ] 11 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2015-05-28" "fechaAceptado" => "2015-08-06" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec821067" "palabras" => array:2 [ 0 => "Chikungunya" 1 => "Arthropathy" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec821066" "palabras" => array:2 [ 0 => "Chikungunya" 1 => "Artropatía" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Chikungunya fever is a mosquito-transmitted viral disease that causes fever, rash and musculoskeletal complaints. The latest may persist for several months, or even years or developed a relapsing course, that deserve an adequate treatment.</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Due to the large outbreak declared in the Caribbean in 2013, imported cases of Chikungunya as well as the risk of autochthonous transmission in case of available vectors have increased in non-endemic countries, like Spain. We described four cases of Chikungunya treated in our clinic.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">La fiebre chikungunya es una infección viral, transmitida por mosquitos, que cursa con fiebre, rash y síntomas musculoesqueléticos que pueden persistir meses, incluso años, de una forma crónica o recidivante precisando adecuado tratamiento.</p><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">La extensa epidemia declarada en el Caribe en 2013<span class="elsevierStyleHsp" style=""></span>ha provocado el aumento de los casos importados en los países no endémicos, así como del riesgo de transmisión autóctona en aquellas zonas donde se encuentran vectores, como es el caso de España. Describimos 4 casos de chikungunya atendidos en nuestras consultas.</p></span>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Richi Alberti P, Steiner M, Illera Martín Ó, Alcocer Amores P, Cobo Ibáñez T, Muñoz Fernández S. Fiebre chikungunya importada en Madrid. Reumatol Clin. 2016;12:226–227.</p>" ] ] "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">ANA, antinuclear antibodies; Anti-CCP, anti-cyclic citrullinated peptide antibodies; F, female; M, male; Neg, negative; NSAID, nonsteroidal anti-inflammatory drug; RF, rheumatoid factor.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Age, years \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Sex \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Symptoms \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Serologic findings chikungunya \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Serologic findings dengue \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">RF/Anti-CCP \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">ANA \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Treatment \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Outcome \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">62 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Fever<br>Rash<br>Arthritis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">IgM+<br>IgG+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">IgM−<br>IgG+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Neg/Neg \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Neg \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NSAID<br>Corticosteroids \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Remission (4<span class="elsevierStyleHsp" style=""></span>m) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">29 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Fever<br>Rash<br>Arthralgia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">IgM+<br>IgG+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">IgM−<br>IgG+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Neg/Neg \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Neg \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NSAID<br>Corticosteroids \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Recurrence remission (4<span class="elsevierStyleHsp" style=""></span>m) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">25 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Fever<br>Rash<br>Arthralgia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">IgM−<br>IgG+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">IgM−<br>IgG− \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Neg/Neg \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Neg \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NSAID<br>Corticosteroids \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Remission (2<span class="elsevierStyleHsp" style=""></span>m) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">26 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Fever<br>Rash<br>Arthralgia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">IgM+<br>IgG+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">IgM−<br>IgG+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Neg/Neg \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Neg \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NSAID<br>Corticosteroids \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Remission (1<span class="elsevierStyleHsp" style=""></span>m) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1386305.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Patient Characteristics.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0055" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Chikungunya virus infection: an overview" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "C. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 7 | 14 | 21 |
| 2024 October | 27 | 26 | 53 |
| 2024 September | 34 | 10 | 44 |
| 2024 August | 42 | 45 | 87 |
| 2024 July | 42 | 25 | 67 |
| 2024 June | 69 | 43 | 112 |
| 2024 May | 44 | 32 | 76 |
| 2024 April | 47 | 25 | 72 |
| 2024 March | 44 | 22 | 66 |
| 2024 February | 33 | 27 | 60 |
| 2024 January | 35 | 26 | 61 |
| 2023 December | 26 | 17 | 43 |
| 2023 November | 32 | 27 | 59 |
| 2023 October | 27 | 27 | 54 |
| 2023 September | 58 | 41 | 99 |
| 2023 August | 34 | 10 | 44 |
| 2023 July | 42 | 25 | 67 |
| 2023 June | 35 | 23 | 58 |
| 2023 May | 35 | 21 | 56 |
| 2023 April | 29 | 15 | 44 |
| 2023 March | 38 | 22 | 60 |
| 2023 February | 34 | 21 | 55 |
| 2023 January | 30 | 18 | 48 |
| 2022 December | 40 | 33 | 73 |
| 2022 November | 38 | 26 | 64 |
| 2022 October | 33 | 24 | 57 |
| 2022 September | 28 | 40 | 68 |
| 2022 August | 25 | 39 | 64 |
| 2022 July | 32 | 48 | 80 |
| 2022 June | 31 | 24 | 55 |
| 2022 May | 30 | 42 | 72 |
| 2022 April | 21 | 38 | 59 |
| 2022 March | 33 | 38 | 71 |
| 2022 February | 27 | 28 | 55 |
| 2022 January | 28 | 37 | 65 |
| 2021 December | 18 | 35 | 53 |
| 2021 November | 34 | 46 | 80 |
| 2021 October | 29 | 52 | 81 |
| 2021 September | 35 | 39 | 74 |
| 2021 August | 27 | 39 | 66 |
| 2021 July | 28 | 30 | 58 |
| 2021 June | 27 | 31 | 58 |
| 2021 May | 35 | 45 | 80 |
| 2021 April | 71 | 85 | 156 |
| 2021 March | 42 | 24 | 66 |
| 2021 February | 45 | 22 | 67 |
| 2021 January | 35 | 25 | 60 |
| 2020 December | 36 | 23 | 59 |
| 2020 November | 76 | 20 | 96 |
| 2020 October | 55 | 21 | 76 |
| 2020 September | 50 | 26 | 76 |
| 2020 August | 26 | 14 | 40 |
| 2020 July | 23 | 12 | 35 |
| 2020 June | 37 | 27 | 64 |
| 2020 May | 34 | 9 | 43 |
| 2020 April | 16 | 19 | 35 |
| 2020 March | 15 | 6 | 21 |
| 2020 February | 2 | 0 | 2 |
| 2018 May | 3 | 0 | 3 |
| 2018 April | 31 | 11 | 42 |
| 2018 March | 41 | 9 | 50 |
| 2018 February | 20 | 7 | 27 |
| 2018 January | 17 | 5 | 22 |
| 2017 December | 17 | 7 | 24 |
| 2017 November | 18 | 8 | 26 |
| 2017 October | 20 | 6 | 26 |
| 2017 September | 15 | 7 | 22 |
| 2017 August | 12 | 7 | 19 |
| 2017 July | 28 | 9 | 37 |
| 2017 June | 39 | 14 | 53 |
| 2017 May | 42 | 14 | 56 |
| 2017 April | 44 | 11 | 55 |
| 2017 March | 27 | 22 | 49 |
| 2017 February | 14 | 9 | 23 |
| 2017 January | 20 | 10 | 30 |
| 2016 December | 55 | 22 | 77 |
| 2016 November | 50 | 29 | 79 |
| 2016 October | 48 | 34 | 82 |
| 2016 September | 62 | 7 | 69 |
| 2016 August | 98 | 21 | 119 |
| 2016 July | 53 | 10 | 63 |
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