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The anti-CCP antibodies and the rheumatoid factor &#40;RF&#41; typically test negative&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Due to its low prevalence in Europe and North America up until now this disease has not been a regular pathology in the everyday clinical practice of rheumatologists in these areas&#46; However&#44; the increase in its incidence in our environment due to greater international travel and global warming suggests that cases should now be reviewed in greater detail&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Clinical Case</span><p id="par0025" class="elsevierStylePara elsevierViewall">A 40 year-old woman presented at our centre in mid-December 2014&#46; She had been on a trip to Cartagena de Indias at the beginning of December that same year&#46; On the third day after her arrival in Colombia she suffered from low mucosa secretion and gingivitis&#44; and right carpal monoarthralgia on the fifth day which one day later developed into symmetrical and distal bilateral polyarthralgias affecting both wrists and ankles&#46; Later proximal and distal interphalangeal arthalgias were added to the first and fourth finger&#46; She did not suffer from myalgias&#46; On the eighth day&#44; on her return to Spain she had a fever of 37&#46;1<span class="elsevierStyleHsp" style=""></span>&#176;<span class="elsevierStyleSmallCaps">C</span> with a nonconfluent maculopapular rash which respected palms of hands and feet&#46; Analysis highlighted a reactive C protein of 1&#46;9<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#44; lymphopenia and monocytosis&#46; Treatment with nonsteroid anti-inflammatory drugs &#40;NSAIDS&#41; and paracetamol were prescribed&#46; On the twelfth day she presented with synovitis and effusion in both wrists and ankles which were confirmed by the rheumatology department&#46; The patient stated she no longer had a fever but did have night diaphoresis&#46; On the eighteenth day the patient suffered from carpal tunnel syndrome&#44; mostly in her right hand&#46; A positive IgM antibody for CHIK was then confirmed serologically and treatment with 30<span class="elsevierStyleHsp" style=""></span>mg of prednisone was initiated&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">In May 2015&#44; functional limitation persisted&#44; with no synovitis&#44; but with serious pain in right wrists&#46; Nuclear magnetic resonance &#40;NMR&#41; imaging of the right wrist in October 2015&#44; 11 months after initiation of symptoms&#44; showed two erosions on the articular side of the right radial epiphysis &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; In our case&#44; the patient continued to suffer for 18 months with arthritis controlled with corticosteroids&#44; initially at a fixed dose and later with a progressively lower dose until it was resolved&#46; Due to the patient&#39;s express desire to conceive&#44; we ruled out initiation of standard synthetic disease-modifying anti-rheumatic drugs &#40;DMARDs&#41;&#46; After one and a half years of clinical symptoms with the presence of articular effusion&#44; the corticoid treatment was withdrawn&#46; The patient currently has no clinical or ultrasound signs of arthritis in any joint although she continues to have pain on extreme flexion of the right wrist&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0035" class="elsevierStylePara elsevierViewall">The possibility of erosive polyarthritis of wrists&#44; hands and ankles has been described in the literature&#44;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">1&#44;4&#44;5</span></a> with participation from uncommon joints on occasions&#44; such as the sternoclavicular or temporomandibular joints&#46; The severity of symptoms in the initial stages of the infection by CHIK could determine time of resolution and risk of development of a long-term arthritis&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">1</span></a> Chronic progression of arthritis should be taken into consideration for a differential diagnosis to prevent persistence over time of an arthritis which could result in joint destruction&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">6</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">The mechanisms that may lead to chronification of arthritis have not been well established&#46; At the moment&#44; the presence of CHIK RNA in synovial fluid in the acute phase has only been demonstrated in animal models&#46; Furthermore it has been demonstrated that macrophage activation in synovial fluid plays a central role in persistent joint inflammation&#46; A study sponsored by the George Washington University is currently trying to show the presence of the virus in human synovial fluid and to assess its role in arthritis chronification&#44; in addition to the presence or nonpresence of the virus in serum&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">7</span></a> The prolonged persistence of IgM in serum could indicate the presence of the virus in tissues&#46; However&#44; there is no evidence that the persistence of the virus would be necessary for the development of a chronic inflammation or that there is a clear relationship between with the severity of the illness&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">One hypothesis is that&#44; through the mechanisms of molecular mimicry and individual genetic conditioning&#44; the infection triggers off an autoimmune reaction which conditions the appearance of a chronic arthritis&#46; Indian scientists concluded significantly in 2014 that the frequency of the allele HLA-DRB1&#42;11 and the haplotype DRB1&#42;11&#47;DQB1&#42;03 was lower in patients than in controls&#44; conferring resistance&#46; They also proved that the haplotype DRB1&#42;04&#47;DQB1&#42;03 was significantly higher in patients with arthritis chronification&#44; and found the allele HLA DQB1&#42;04 solely in this patient group&#46; In 2010&#44; the same work group&#44; from the longitudinal follow-up of a cohort of 203 patients for 10 months&#44; confirmed that only 51&#37; of patients were cured at the end of nine months&#46; They observed that of those who had joint pain &#40;74&#37;&#41;&#44; 36&#37; met the American College of Rheumatology criteria to classify them as having rheumatoid arthritis and tested 20 of these for RF and anti-CCP&#46; All serologies were negative except for one patient who tested positive for anti-CCP positive and who showed signs of joint destruction by NMR&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">1&#44;8</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">If we review data from the 2006 outbreak on Reunion Island&#44; we see that the majority of young patients recovered&#44; with prevalence of persistence clearly higher in people over 60&#44; who also had a higher viral load&#46; Rapid establishment of an innate response was shown with an increase in the activation of NK cells and CD4 lymphocytes&#44; followed by a weak response of the cytokins Th1&#47;Th2&#44; and high levels of IFN-alpha&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">9</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">Cases have been described in the literature where chronic arthritis follows an infection by CHIK&#46; Some of these patients despite post-infectious origin&#44; were treated with DMARDs due to the chronic nature of the condition&#44; with favourable outcome&#46; We should highlight that the efficacy of the DMARDs in this indication has not been accurately assessed&#46; French researchers have postulated that the resistance or dependence of corticoids beyond 3 months would be highly suggestive of chronification&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">10</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">At present&#44; treatment is essentially one of support&#44; including anti-inflammatory drugs&#46; Antiviral drugs and chloroquine have not proven to be effective and there is currently no available vaccine&#46; For selected chronic patients&#44; the corticosteroids methotrexate and other immunomodulatory agents may be of use&#46;<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">10&#44;11</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conclusion</span><p id="par0065" class="elsevierStylePara elsevierViewall">Scientific production aimed at this issue is limited and the evidence in all aspects is scarce&#46; Although arthritis by CHIK are self-limiting and mild in somewhat more than half of the occasions&#44; in several of the series up to 49&#37; of patients chronic progression took over 9 months&#44; sometimes causing joint destructions&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">1</span></a> It is unknown whether early establishment of treatment would lead to reduction of the probability of suffering from erosions&#46; Diagnosis is serological&#46; IgM presents from day one to day twelve of symptom initiation and IgG from the second month onwards although it is possible that raised levels will last for years&#46; It should be noted that possible laboratory cross-reactivity exists or a co-infection may occur since the vector is shared with the dengue&#46; Serological and clinical evolution is highly variable and genetic conditioning may play an essential role in the etiopathogenesis of chronification&#46; The infection generates antibodies which protect the person throughout their life&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Funding</span><p id="par0070" class="elsevierStylePara elsevierViewall">No financing sources exist&#44; all the information was obtained during standard clinical practice&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conflict of Interests</span><p id="par0075" class="elsevierStylePara elsevierViewall">All the authors have no conflicts of interest to declare&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Chikungunya virus infection &#40;CHIKV&#41; is associated with joint involvement in half of the cases&#46; This can lead to erosive arthritis which&#44; given the high intervariability of clinical and serological presentations&#44; and the probable role of genetic conditioning in the severity and chronification of the condition&#44; represents a great diagnostic and therapeutic challenge&#46; There is an important lack of scientific evidence that would enable us to characterize the variability of the patient and choose the most appropriate approach&#46;</p></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">La infecci&#243;n por virus Chikungunya &#40;CHIKV&#41; presenta afectaci&#243;n articular en la mitad de las ocasiones&#46; Esta afectaci&#243;n puede derivar en una artritis erosiva que&#44; dada la elevada intervariabilidad en la presentaci&#243;n tanto cl&#237;nica como serol&#243;gica y el probable papel del condicionamiento gen&#233;tico en la gravedad y cronificaci&#243;n del cuadro&#44; supone un gran reto diagn&#243;stico y terap&#233;utico&#46; Existe una importante falta de evidencia cient&#237;fica que nos permita caracterizar la variabilidad del paciente y decidir el abordaje m&#225;s adecuado&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Castro-Dom&#237;nguez F&#44; Salman-Monte TC&#44; Ojeda F&#44; Corzo P&#44; Carri&#243;n-Barber&#225; I&#44; Garcia-Duitama IC&#44; et al&#46; Artritis erosiva por virus Chikungunya&#44; caso y revisi&#243;n de la literatura&#46; Reumatol Clin&#46; 2019&#59;15&#58;e119&#8211;e121&#46;</p>"
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">NMR imaging enhanced in T1 &#40;A&#58; coronal slice&#44; B&#58; axial plane&#41; and proton density with fat suppression in sagittal plane &#40;C&#41;&#46; Erosion in the distal articular surface of the radium &#40;arrows&#41; may be observed with no clear spinal oedema in the underlying bone&#46;</p>"
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Case Report
Chikungunya-related Erosive Arthritis: Case Report and Literature Review
Artritis erosiva por virus Chikungunya, caso y revisión de la literatura
Francisco Castro-Domíngueza,
Corresponding author
61362@parcdesalutmar.cat

Corresponding author.
, Tarek Carlos Salman-Montea, Fabiola Ojedaa, Patricia Corzoa, Irene Carrión-Barberáa, Ivan Camilo Garcia-Duitamab, Jordi Monforta
a Servicio de Reumatología, Hospital del Mar, Parc de Salut Mar, IMIM, Barcelona, Spain
b Sección de Radiología Musculoesquelética, Servicio de Radiología, Hospital del Mar, Parc de Salut Mar, Barcelona, Spain
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        "titulo" => "Artritis erosiva por virus Chikungunya&#44; caso y revisi&#243;n de la literatura"
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">NMR imaging enhanced in T1 &#40;A&#58; coronal slice&#44; B&#58; axial plane&#41; and proton density with fat suppression in sagittal plane &#40;C&#41;&#46; Erosion in the distal articular surface of the radium &#40;arrows&#41; may be observed with no clear spinal oedema in the underlying bone&#46;</p>"
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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">Alphaviruses are associated with inflammatory forms of clinically severe arthritis which may be self-limiting or persist over time&#44; mimicking persistent forms of noninfectious arthritis&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">The Chikungunya &#40;CHIK&#41; virus is an arbovirus of the Togaviridae family of the alphavirus species&#44; as are also the O&#8217;nyong-nyong virus&#44; the Sindbis virus&#44; the Ross river virus&#44; the Mayaro virus&#44; the Semliki virus and the Barmah virus&#46; Discovered in Tanzania in 1952&#44; the CHIK has widely extended&#44; causing massive explosive outbreaks in the region of the Indian Ocean islands&#46; It was traditionally perceived as a tropical disease until an outbreak occurred in Italy in 2007&#46; Vector distribution is extensive &#40;<span class="elsevierStyleItalic">Aedes aegypti</span> and <span class="elsevierStyleItalic">Aedes albopictus</span>&#41; and since the end of 2013 infections by CHIK have spread from the Southern states of the United States to the north of Argentina&#46; These are the same mosquitoes responsible for the transmission of dengue fever&#44; yellow fever&#44; Zika fever&#44; West Nile fever&#44; Japanese encephalitis and Eastern equine encephalitis virus&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">The standard initial disease symptoms are high fever from 3 to 10 days&#44; with half of patients also suffering from joint pain and&#47;or effusion<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">1</span></a> which starts 2&#8211;5 days after the fever and usually includes the involvement of over 10 joints symmetrically&#44; with hands&#44; followed by wrists&#44; and ankles being the most commonly affected&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">2&#44;3</span></a> Participation of the axial skeleton is observed in less than half of the patients depending on the series&#46; The anti-CCP antibodies and the rheumatoid factor &#40;RF&#41; typically test negative&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Due to its low prevalence in Europe and North America up until now this disease has not been a regular pathology in the everyday clinical practice of rheumatologists in these areas&#46; However&#44; the increase in its incidence in our environment due to greater international travel and global warming suggests that cases should now be reviewed in greater detail&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Clinical Case</span><p id="par0025" class="elsevierStylePara elsevierViewall">A 40 year-old woman presented at our centre in mid-December 2014&#46; She had been on a trip to Cartagena de Indias at the beginning of December that same year&#46; On the third day after her arrival in Colombia she suffered from low mucosa secretion and gingivitis&#44; and right carpal monoarthralgia on the fifth day which one day later developed into symmetrical and distal bilateral polyarthralgias affecting both wrists and ankles&#46; Later proximal and distal interphalangeal arthalgias were added to the first and fourth finger&#46; She did not suffer from myalgias&#46; On the eighth day&#44; on her return to Spain she had a fever of 37&#46;1<span class="elsevierStyleHsp" style=""></span>&#176;<span class="elsevierStyleSmallCaps">C</span> with a nonconfluent maculopapular rash which respected palms of hands and feet&#46; Analysis highlighted a reactive C protein of 1&#46;9<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#44; lymphopenia and monocytosis&#46; Treatment with nonsteroid anti-inflammatory drugs &#40;NSAIDS&#41; and paracetamol were prescribed&#46; On the twelfth day she presented with synovitis and effusion in both wrists and ankles which were confirmed by the rheumatology department&#46; The patient stated she no longer had a fever but did have night diaphoresis&#46; On the eighteenth day the patient suffered from carpal tunnel syndrome&#44; mostly in her right hand&#46; A positive IgM antibody for CHIK was then confirmed serologically and treatment with 30<span class="elsevierStyleHsp" style=""></span>mg of prednisone was initiated&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">In May 2015&#44; functional limitation persisted&#44; with no synovitis&#44; but with serious pain in right wrists&#46; Nuclear magnetic resonance &#40;NMR&#41; imaging of the right wrist in October 2015&#44; 11 months after initiation of symptoms&#44; showed two erosions on the articular side of the right radial epiphysis &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; In our case&#44; the patient continued to suffer for 18 months with arthritis controlled with corticosteroids&#44; initially at a fixed dose and later with a progressively lower dose until it was resolved&#46; Due to the patient&#39;s express desire to conceive&#44; we ruled out initiation of standard synthetic disease-modifying anti-rheumatic drugs &#40;DMARDs&#41;&#46; After one and a half years of clinical symptoms with the presence of articular effusion&#44; the corticoid treatment was withdrawn&#46; The patient currently has no clinical or ultrasound signs of arthritis in any joint although she continues to have pain on extreme flexion of the right wrist&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0035" class="elsevierStylePara elsevierViewall">The possibility of erosive polyarthritis of wrists&#44; hands and ankles has been described in the literature&#44;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">1&#44;4&#44;5</span></a> with participation from uncommon joints on occasions&#44; such as the sternoclavicular or temporomandibular joints&#46; The severity of symptoms in the initial stages of the infection by CHIK could determine time of resolution and risk of development of a long-term arthritis&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">1</span></a> Chronic progression of arthritis should be taken into consideration for a differential diagnosis to prevent persistence over time of an arthritis which could result in joint destruction&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">6</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">The mechanisms that may lead to chronification of arthritis have not been well established&#46; At the moment&#44; the presence of CHIK RNA in synovial fluid in the acute phase has only been demonstrated in animal models&#46; Furthermore it has been demonstrated that macrophage activation in synovial fluid plays a central role in persistent joint inflammation&#46; A study sponsored by the George Washington University is currently trying to show the presence of the virus in human synovial fluid and to assess its role in arthritis chronification&#44; in addition to the presence or nonpresence of the virus in serum&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">7</span></a> The prolonged persistence of IgM in serum could indicate the presence of the virus in tissues&#46; However&#44; there is no evidence that the persistence of the virus would be necessary for the development of a chronic inflammation or that there is a clear relationship between with the severity of the illness&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">One hypothesis is that&#44; through the mechanisms of molecular mimicry and individual genetic conditioning&#44; the infection triggers off an autoimmune reaction which conditions the appearance of a chronic arthritis&#46; Indian scientists concluded significantly in 2014 that the frequency of the allele HLA-DRB1&#42;11 and the haplotype DRB1&#42;11&#47;DQB1&#42;03 was lower in patients than in controls&#44; conferring resistance&#46; They also proved that the haplotype DRB1&#42;04&#47;DQB1&#42;03 was significantly higher in patients with arthritis chronification&#44; and found the allele HLA DQB1&#42;04 solely in this patient group&#46; In 2010&#44; the same work group&#44; from the longitudinal follow-up of a cohort of 203 patients for 10 months&#44; confirmed that only 51&#37; of patients were cured at the end of nine months&#46; They observed that of those who had joint pain &#40;74&#37;&#41;&#44; 36&#37; met the American College of Rheumatology criteria to classify them as having rheumatoid arthritis and tested 20 of these for RF and anti-CCP&#46; All serologies were negative except for one patient who tested positive for anti-CCP positive and who showed signs of joint destruction by NMR&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">1&#44;8</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">If we review data from the 2006 outbreak on Reunion Island&#44; we see that the majority of young patients recovered&#44; with prevalence of persistence clearly higher in people over 60&#44; who also had a higher viral load&#46; Rapid establishment of an innate response was shown with an increase in the activation of NK cells and CD4 lymphocytes&#44; followed by a weak response of the cytokins Th1&#47;Th2&#44; and high levels of IFN-alpha&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">9</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">Cases have been described in the literature where chronic arthritis follows an infection by CHIK&#46; Some of these patients despite post-infectious origin&#44; were treated with DMARDs due to the chronic nature of the condition&#44; with favourable outcome&#46; We should highlight that the efficacy of the DMARDs in this indication has not been accurately assessed&#46; French researchers have postulated that the resistance or dependence of corticoids beyond 3 months would be highly suggestive of chronification&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">10</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">At present&#44; treatment is essentially one of support&#44; including anti-inflammatory drugs&#46; Antiviral drugs and chloroquine have not proven to be effective and there is currently no available vaccine&#46; For selected chronic patients&#44; the corticosteroids methotrexate and other immunomodulatory agents may be of use&#46;<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">10&#44;11</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conclusion</span><p id="par0065" class="elsevierStylePara elsevierViewall">Scientific production aimed at this issue is limited and the evidence in all aspects is scarce&#46; Although arthritis by CHIK are self-limiting and mild in somewhat more than half of the occasions&#44; in several of the series up to 49&#37; of patients chronic progression took over 9 months&#44; sometimes causing joint destructions&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">1</span></a> It is unknown whether early establishment of treatment would lead to reduction of the probability of suffering from erosions&#46; Diagnosis is serological&#46; IgM presents from day one to day twelve of symptom initiation and IgG from the second month onwards although it is possible that raised levels will last for years&#46; It should be noted that possible laboratory cross-reactivity exists or a co-infection may occur since the vector is shared with the dengue&#46; Serological and clinical evolution is highly variable and genetic conditioning may play an essential role in the etiopathogenesis of chronification&#46; The infection generates antibodies which protect the person throughout their life&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Funding</span><p id="par0070" class="elsevierStylePara elsevierViewall">No financing sources exist&#44; all the information was obtained during standard clinical practice&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conflict of Interests</span><p id="par0075" class="elsevierStylePara elsevierViewall">All the authors have no conflicts of interest to declare&#46;</p></span></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">La infecci&#243;n por virus Chikungunya &#40;CHIKV&#41; presenta afectaci&#243;n articular en la mitad de las ocasiones&#46; Esta afectaci&#243;n puede derivar en una artritis erosiva que&#44; dada la elevada intervariabilidad en la presentaci&#243;n tanto cl&#237;nica como serol&#243;gica y el probable papel del condicionamiento gen&#233;tico en la gravedad y cronificaci&#243;n del cuadro&#44; supone un gran reto diagn&#243;stico y terap&#233;utico&#46; Existe una importante falta de evidencia cient&#237;fica que nos permita caracterizar la variabilidad del paciente y decidir el abordaje m&#225;s adecuado&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Castro-Dom&#237;nguez F&#44; Salman-Monte TC&#44; Ojeda F&#44; Corzo P&#44; Carri&#243;n-Barber&#225; I&#44; Garcia-Duitama IC&#44; et al&#46; Artritis erosiva por virus Chikungunya&#44; caso y revisi&#243;n de la literatura&#46; Reumatol Clin&#46; 2019&#59;15&#58;e119&#8211;e121&#46;</p>"
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Article information
ISSN: 21735743
Original language: English
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