Recommendations of the Brazilian Society of Rheumatology for diagnosis and treatment of Chikungunya fever. Part 1 – Diagnosis and special situations

Abstract

Chikungunya fever has become a relevant public health problem in countries where epidemics occur. Until 2013, only imported cases occurred in the Americas, but in October of that year, the first cases were reported in Saint Marin island in the Caribbean. The first autochthonous cases were confirmed in Brazil in September 2014; until epidemiological week 37 of 2016, 236,287 probable cases of infection with Chikungunya virus had been registered, 116,523 of which had serological confirmation. Environmental changes caused by humans, disorderly urban growth and an ever-increasing number of international travelers were described as the factors responsible for the emergence of large-scale epidemics. Clinically characterized by fever and joint pain in the acute stage, approximately half of patients progress to the chronic stage (beyond 3 months), which is accompanied by persistent and disabling pain. The aim of the present study was to formulate recommendations for the diagnosis and treatment of Chikungunya fever in Brazil. A literature review was performed in the MEDLINE, SciELO and PubMed databases to ground the decisions for recommendations. The degree of concordance among experts was established through the Delphi method, involving 2 in-person meetings and several online voting rounds. In total, 25 recommendations were formulated and divided into 3 thematic groups: (1) clinical, laboratory and imaging diagnosis; (2) special situations; and (3) treatment. The first 2 themes are presented in part 1, and treatment is presented in part 2.

Chikungunya fever: General and oral healthcare implications

“…Hence, during epidemic situations, in the presence of acute fever, arthralgia/severe arthritis, with or without rash, the possibility of chikungunya fever should be strongly considered. However, other acute febrile diseases should be included in the differential diagnosis, especially in instances of severe and/or atypical clinical disease (Marques et al., ; Marques et al., ,b).…”

“…In epidemic situations, patients in the acute phase may have the diagnosis established based on clinical–epidemiological criteria, without confirmatory serology or associated hematology. For patients at risk (elderly, pregnant, children aged under 2 years or persons with comorbidities), the recommendation is that only the full blood cell count (FBC) should be requested (Marques et al., ; Marques et al., ,b). A more detailed laboratory evaluation may be necessary according to the patient's general conditions, comorbidities, and drug use, especially in elderly patients (Brazilian Medical Council, ; Simon et al., ).…”

“…In the chronic phase, in addition to the routine examinations (FBC, erythrocyte sedimentation rate, and CRP), the need for autoantibody request should be evaluated if the clinical presentation is suggestive of autoimmune disease as well as evaluation of possible comorbidities. Analysis of synovial fluid may be necessary to confirm the inflammatory nature of joint involvement and to aid in differential diagnosis including gout and septic arthritis (Marques et al., ; Marques et al., ,b; Simon et al., ).…”

“…As the clinical–epidemiological criteria used for the diagnosis of chikungunya fever (WHO, ) in epidemic situations show high agreement with the result of the specific serology for CHIKV (Marques et al., ; Marques et al., ,b), it is not recommended to perform this test for the diagnosis of uncomplicated cases. Because of the high attack rate of CHIKV (20% to 50% of the exposed population) (Cunha et al., ), performing specific serology for all cases is practically unfeasible from an economic point of view.…”

“…Patients also require advice concerning posture control, exercises, and graded return to normal motor function. This may include heat, active free, resisted, proprioceptive and aerobic exercises, stretching, manual therapy, and aquatic physiotherapy (Marques et al., ,b).…”