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Morbilliform skin rash with prominent involvement of the palms in Chikungunya fever

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An outbreak of chikungunya occurred in Central Italy in the summer of 2017. During the outbreak, two siblings with fever and joint pain developed a morbilliform skin rash with prominent involvement of the palms. Knowledge of the characteristics of chikungunya exanthem is important to adddress clinical diagnosis.
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Case
illustrated
Morbilliform
skin
rash
with
prominent
involvement
of
the
palms
in
Chikungunya
fever
Maria
Laura
Tini
a
,
Giovanni
Rezza
b,
*
a
ASL-RM2,
Roma,
Italy
b
Department
of
Infectious
Diseases,
Istituto
Superiore
di
Sanità,
Roma,
Italy
A
R
T
I
C
L
E
I
N
F
O
Article
history:
Received
24
May
2018
Received
in
revised
form
2
July
2018
Accepted
2
July
2018
Keywords:
Chikungunya
Skin
rash
A
B
S
T
R
A
C
T
An
outbreak
of
chikungunya
occurred
in
Central
Italy
in
the
summer
of
2017.
During
the
outbreak,
two
siblings
with
fever
and
joint
pain
developed
a
morbilliform
skin
rash
with
prominent
involvement
of
the
palms.
Knowledge
of
the
characteristics
of
chikungunya
exanthem
is
important
to
adddress
clinical
diagnosis.
©
2018
Published
by
Elsevier
Ltd.
This
is
an
open
access
article
under
the
CC
BY-NC-ND
license
(http://
creativecommons.org/licenses/by-nc-nd/4.0/).
A
21
year
old
man
living
in
Rome
presented,
on
August
26,
2017,
with
a
two-day
history
of
high
fever
(39.6
C),
malaise,
joint
pain,
and
a
morbilliform
skin
rash.
The
skin
rash
affected
the
face,
trunk,
upper
limbs,
and
lower
limbs
(Fig.
1).
Weak nes s
and
joint
pain
(ankles
and
wrists
were
slightly
swollen)
lasted
for
over
two
months
after
recovery
from
the
acute
disease.
His
sister,
a
15
year
old
girl,
developed
the
same
symptoms
with
fever
onset
(38
C)
on
August
25.
The
rash
developed
on
the
2nd
day.
Joint
pain
affected
the
wrists,
which
appeared
swollen,
lasting
for
two
months
after
acute
disease
onset.
The
exanthema
involved
the
palm
of
the
hands,
particularly
the
ngertips,
which
were
intensively
ushed
in
both
patients
(Figs.
2
and
3).
Since
an
outbreak
of
chikungunya
had
been
identied
near
the
city
of
Roma,
this
diagnosis
was
hypothesized.
On
mid-September,
blood
samples
sent
to
the
Spallanzani
hospital
laboratory
in
Roma
were
positive
for
anti-chikungunya
virus
antibodies
(IgM
titer
was
1:320
and
IgG
1:640
in
both
patients).
Blood
counts
and
liver
enzymes
were
within
the
limits.
Chikungunya
is
a
vector-borne
disease,
caused
by
an
Alphavirus
transmitted
by
Aedes
spp.
mosquitoes.
In
Italy,
two
chikungunya
fever
outbreaks
occurred
in
2007
and
in
2017
[1,2].
During
the
last
outbreak,
sporadic
cases
and
small
clusters
were
reported
also
in
the
city
of
Rome
[2].
Chikungunya
fever
is
characterized
by
fever,
prominent
and
sometimes
long-lasting
joint
pain,
and
a
generalized
maculo-papular
skin
rash.
Differently
from
measles,
after
an
initial
facial
ushing,
the
face
is
often
spared
by
the
exanthema.
Palm
involvement
is
not
pathognomonic
of
chikungunya
fever,
and
has
been
described
also
in
other
alphavirus
fevers,
such
as
Mayaro
and
Ross
River
disease
[3,4].
In
conclusion,
a
diagnosis
of
chikungunya
fever
should
be
considered
when
cases
of
fever
with
joint
pain,
accompanied
by
a
skin
rash,
which
may
involve
the
palm
of
the
hands,
occur
during
the
hot
season
in
areas
with
presence
of
Aedes
spp.
mosquitoes.
Declaration
of
interests
No
competing
interests.
Authors
statement
The
authors
declare
they
do
not
have
any
conict
of
interest,
they
received
written
informed
consent
from
the
patients,
and
all
the
work
has
been
done
in
complete
transparency.
Contributors
MLTcared for the patients, and
GR
supervisedand wrotethe report.
*
Corresponding
author
at:
Department
of
Infectious
Diseases,
Istituto
Superiore
di
Sanità,
Viale
Regina
Elena,
299,
00161,
Roma,
Italy.
E-mail
address:
giovanni.rezza@iss.it
(G.
Rezza).
https://doi.org/10.1016/j.idcr.2018.e00421
2214-2509/©
2018
Published
by
Elsevier
Ltd.
This
is
an
open
access
article
under
the
CC
BY-NC-ND
license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).
IDCases
13
(2018)
e00421
Contents
lists
available
at
ScienceDirect
IDCases
journal
homepage:
www.elsevier.com/locate/idcr
Acknowledgements
We
thank
the
lab
of
the
INMI
Spallanzani
in
Roma
for
CHIKV
serology.
We
also
thank
the
two
patients
and
their
mother
for
the
collaboration
and
for
having
authorized
the
publication.
References
[1]
Rezza
G.,
Nicoletti
L,
Angelini
R,
et
al.
Infections
with
chikungunya
virus
in
Italy:
an
outbreak
in
a
temperate
region.
Lancet
2007;370:18406.
[2]
Venturi
G,
Di
Luca
M,
Fortuna
C,
et
al.
Detection
of
a
chikungunya
outbreak
in
Central
Italy,
August
to
September
2017.
Euro
Surveill
2017;22(September
(39)),
doi:http://dx.doi.org/10.2807/1560-7917.ES.2017.22.39.17-00646.
[3]
Pincus
LB,
Grossman
ME,
Fox
LP.
The
exanthema
of
dengue
fever:
clinical
features
of
two
tourists
traveling
abroad.
J
Am
Acad
Dermatol
2008;58:30816.
[4]
Keighley
CT,
Saunderson
RB,
Kok
J,
Dwyer
DE.
Viral
exanthems.
Curr
Opin
Infect
Dis
2015;28:13950.
Fig.
1.
Manifestations
of
chikungunya
skin
rash.
Skin
rash
on
patients
leg.
Fig.
2.
Manifestations
of
chikungunya
skin
rash.
Palm
involvement
on
the
hand
of
the
21-year-old
man.
Fig.
3.
Manifestations
of
chikungunya
skin
rash.
Palm
involvement
of
the
15
year-
old
girl.
2
M.L.
Tini,
G.
Rezza
/
IDCases
13
(2018)
e00421
... During 2017, Italy experienced also a large spread of measles, with almost 5,000 cases reported, of which 1 out of 3 cases were in the Lazio region (incidence rate: 28.8 cases/100,000 inhabitants). It should be noticed that CHIKV-related skin rash is usually morbilliform (measles-like) [31][32][33], with or without acral and facial edema, mucosal, and genital and intertriginous ulceration, and vesiculobullous eruptions are more likely to occur in children. Differently from measles, after an initial facial flushing, the face is often spared by the CHIKV-related exanthema [31]. ...
... It should be noticed that CHIKV-related skin rash is usually morbilliform (measles-like) [31][32][33], with or without acral and facial edema, mucosal, and genital and intertriginous ulceration, and vesiculobullous eruptions are more likely to occur in children. Differently from measles, after an initial facial flushing, the face is often spared by the CHIKV-related exanthema [31]. Therefore, it is possible to speculate that some CHIKV cases with nonsevere joint involvement in the acute phase of infection may have been clinically underrecognized, and thus under-reported. ...
Article
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Chikungunya virus (CHIKV) is a mosquito-borne infection that is emerging in temperate areas of Europe, following the expansion of one of its vector species, Aedes albopictus. Although CHIKV fever is a self-limiting disease, with a clinical syndrome often resolving within few days, it can also cause severe sequelae, including chronic polyarthralgia lasting up to 5 years. Additionally, CHIKV outbreaks may limit blood bank donations, adding economic burden on the health system. Public health authorities in Europe need to increase their preparedness against this emerging threat. Two large CHIKV outbreaks occurred in Italy in 2007 and 2017, with hundreds of cases and significant geographical spread. The aim of this paper is to review and compare the 2 Italian outbreaks in terms of available estimates of key epidemiological features, patient clinical presentation, virus and immunological characteristics, and public health response. Recommendations for public health and future directions for research are also discussed and highlighted. Key results Both outbreaks started in small towns, but cases were also detected in nearby larger cities where transmission was limited to small clusters. The time spans between the first and the last symptom onsets were similar between the 2 outbreaks, and the delay from the symptom onset of the index case and the first case notified was considerable. Comparable infection and transmission rates were observed in laboratory. The basic reproductive number (R0) was estimated in the range of 1.8–6 (2007) and 1.5–2.6 (2017). Clinical characteristics were similar between outbreaks, and no acute complications were reported, though a higher frequency of ocular symptoms, myalgia, and rash was observed in 2017. Very little is known about the immune mediator profile of CHIKV-infected patients during the 2 outbreaks. Regarding public health responses, after the 2007 outbreak, the Italian Ministry of Health developed national guidelines to implement surveillance and good practices to prevent and control autochthonous transmission. However, only a few regional authorities implemented it, and the perception of outbreak risk and knowledge of clinical symptoms and transmission dynamics by general practitioners remained low. Major conclusions Efforts should be devoted to developing suitable procedures for early detection of virus circulation in the population, possibly through the analysis of medical records in near real time. Increasing the awareness of CHIKV of general practitioners and public health officials through tailored education may be effective, especially in small coastal towns where the outbreak risk may be higher. A key element is also the shift of citizen awareness from considering Aedes mosquitoes not only as a nuisance problem but also as a public health one. We advocate the need of strengthening the surveillance and of promoting the active participation of the communities to prevent and contain future outbreaks.
... In the acute phase of the disease, the most common symptoms are fever, polyarthralgia, and rash, but headache, fatigue, rash, nausea, vomiting, conjunctivitis, and myalgia may occur (Simon et al., 2008). As dermal changes, morbilliform and maculopapular eruptions of erythematous lesions on the trunk, face, and extremities were quite common findings, with occurrence in 20 to 80% of those infected (Bandyopadhyay and Ghosh, 2010;Kumar et al., 2017;Rueda et al., 2018;Spoto et al., 2018;Tini and Rezza, 2018). The rash can be extensive, affecting more than 90% of the skin (Burt et al., 2017). ...
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