Chikungunya in a Neonate

1. Chikungunya in a Neonate Presenter: Cherry May V. Villar, M.D. First Year Resident Adviser: Renee Joy P. Neri, M.D. Ambulatory Pediatrics, Consultant

2. Objectives To present a case of Chikungunya in a neonate To discuss the epidemiology, etiology, pathogenesis, differential diagnosis, diagnosis, management, recommendations, prevention and prognosis of Chikungunya infection especially in a neonate

3. General Data: Z.D. 16 day old, male Filipino, Catholic Meycauyan, Bulacan Informant: mother Reliability: 90% Chief complaint: fever

4. History of Present Illness Born to 29 year old G2P2 (2002) non smoker, non alcoholic beverage drinker mother Pre natal check up started at 1 month AOG with an OB-GYNE Known hyperthyroid but repeat thyroid function test were of normal results, hence medications were discontinued Ancillaries: Test for Hepatitis B antigen -negative. Ultrasound (3rd, 6th, 8th months age of gestations) - normal No exposure to radiation and teratogens. Took multivitamins throughout the course of pregnancy. vaccinated with Flu and tetanus toxoid during the first trimester of pregnancy.

5. (+) possible Chikungunya fever among their relatives within the compound • One day prior to delivery - sudden onset of rashes described as slightly pruritic erythematous maculopapular lesions at abdominal area. Consult done with her OB-GYN. Internal examination revealed cervical dilation of 4cm, hence advised close follow up • Few hours prior to delivery, still with rashes, the mother had undocumented fever associated with joint pains on both hands and ankles. • PE: Internal examination revealed cervical dilatation of 5cm A> German measles vs Chikungunya fever P> Admission Labour for 2 hours

6. Delivered full term via normal spontaneous delivery at Meycauayan Doctors Hospital assisted by an Obstetrician. • The patient was reported with good cry and activity • No meconium stained amniotic fluid and cord coil was noted loosely at the neck area. No jaundice, cyanosis nor difficulty of breathing noted. Birth weight was 2850 grams. Routine newborn care rendered: Vitamin K, erythromycin eye ointment, BCG. and Hepatitis B vaccine were given. • Meconium passage and adequate urine output was noted in less than 24 hours of life. • Newborn screening was done and revealed normal results. Patient was then discharged after 48 hours.

7. At home the patient was active, good suck, consuming 1-2 ounces of milk formula (Enfalac) every 2 to 3 hours. • He had adequate urine output with regular bowel movement. • On the 3rd day of life patient had low - moderate grade fever associated with erythematous maculopapular rashes on the trunk, both upper and lower extremities, jaundice on face and trunk. • Patient was brought to a Pediatrician and was advised admission.

8. Patient was admitted at Meycauayan Doctors Hospital A>Neonatal Sepis vs Pneumonia Hyperbilirubinemia Secondary to ABO incompatibility P> Phototherapy , given IVIg transfusion IV antibiotics: Ampicillin (100mkdose) and Cefotaxime (50mkdose) for 7 days. • During the 2nd hospital stay, patient had 1 episode of jerky movement of extremities and upward rolling of eyeballs, no cyanosis duration of approximately less than 1 minute. • Pertinent works up showed normal HGT levels, electrolytes revealing decreased calcium. A> Acute Symptomatic seizure probably bacterial meningitis/ Viral encephalitis. P> IV calcium and loaded and maintained with Phenobarbital x 3 days. Cranial ultrasound , blood culture, CSF analysis - unremarkable Request for EEG, Torch assay, Chikungunya titers where made however not done.

9. (+) episodes of heart rate with irregulary irregular rhythm. • CK-MB - revealed slight elevation • 2D Echo showed patent Foramen Ovale • 15LECG – first degree AV block A>Viral Myocarditis • Patient was then discharged after 10 days • Final diagnosis: Myocarditis; Meningoencephalitis, resolving; Hyperbilirubinemia sec to ABO incompatibility, resolved. • 16th day of life- recurrence of fever (Temp 38 c) associated with circumoral cyanosis and fair suck. • Patient remained active with no other associated symptoms such as difficulty of breathing, and seizure. Patient was brought to our institution and was subsequently admitted.

10. Family History (+) hypertension – paternal side (-) DM, PTB, CA, epilepsy

11. Environmental History lives in rented house inside a compound near an industrial area in Meycauayan, Bulacan. The house is well lit and ventilated, with 4 household members. Water for drinking is distilled water, not boiled prior to consumption. Garbage is collected thrice a week, unsegregated. No exposure to pesticides, toxic substances and radiation Presence of animals in the community such as dogs, cats, and rats.

12. Nutritional History Immunization History • BCG – 1 • Hepatitis B -1 1-2 ounces of milk formula (Enfalac) every 2 to 3 hours. Growth & Developmental History • Lies in flexed position, head lags, preference to human face (+) Dolls eye

13. Review of Systems General: (-) loss of appetite, (-) weight gain/loss, (-) decrease activity Cutaneous: (-) active dermatosis HEENT: (-) nasoaural discharge, (-) epistaxis Cardiovascular: (-) cyanosis, (-) difficulty in feeding Respiratory: (-) cough, (-) difficulty of breathing Genitourinary: (-) decreased urine output, (-) edema of hands and feet Endocrine: (-) hypothermia Nervous/Behavior: (-) tremors, (-) convulsions Musculoskeletal: (-) limitation of motion Hematopoietic: (-) petechiae, (-) easy bruisability

14. Physical Examination Asleep but arousable, not in distress BP 80/50 CR 142 RR 36 T: 38.1 C Wt: 2.8 kgs ( z = 0) Lt: 48cm ( z = 0) HC: 33cm CC: 32cm AC: 31 cm (p10-25) HEAD: Soft, patent, anterior fontanelle, good hair distribution SKIN: No jaundice, warm skin, no active dermatoses

15. HEENT: normocephalic, open flat anterior and posterior fontanelles,pink conjunctivae anicteric sclerae, pink moist lips and oral mucosa, no nasal or ear discharge, supple neck, no neck vein distention, • Chest/lungs: symmetrical chest expansion, no retractions, no chest lag, clear and equal breath sounds • Cardiovascular: adynamic precordium, regular rate, regular rhythm, PMI at 4th ICS LMCL, no murmur • Abdomen: globular, no visible veins, normoactive bowel sounds, soft, dried non erythematous umbilical area. No palpable mass no organomegaly • Genitalia: grossly male, descended testis bilateral, no penile discharge • Rectum: patent anal canal • Extremities: full pulses warm extremities, no edema

16. Neurologic PE • Cranial Nerves: I: not assessed II: pupils 2-3 mm EBRTL, (+) ROR, no hemorrhages, no papilledema III, IV, VI: full and equal extraocular muscle movement V: intact sensation of the face, with good masseter, temporalis tone VII: no facial asymmetry IX, X: good gag reflex, uvula in midline XI: turns head side to side XII: tongue midline, no fasciculation • Motor: moves all extremities spontaneously and equally, good tone and bulk. • Sensory: response to tactile stimulation • Cerebellar: no nystagmus • Deep tendon reflex: +2 in all extremities • Pathologic reflexes: (+) babinski, bilateral, no clonus, no nuchal rigidity

17. Elevated bilirubin levels • Maternal BT “O” positive, patient’s BT “A” positive • (+) seizure • Septic work up – unremarkable • (+) irregularly irregular HR, ECG - first degree AV block • Elevated CKMB Salient Features 16 day old, male Chief complaint: fever (+) maternal exposure to possible Chikungunya infection Maternal, fever, joint pains, erythematous maculopapular rashes on the trunk, both upper and lower extremities, jaundice on face and trunk.

18. Hyperbilirubinemia secondary to ABO incompatibility Neonatal Sepsis Differential Diagnosis Inborn error of metabolism/Metabolic Encephalopathy

19. Working Impression Full Term, male, Neonatal Chikungunya infection Health care associated infection

20. Epidemiology • Chikungunya virus (CHIKV) • mosquito-transmitted alphavirus • first isolated in Tanzania in 1952 • main vectors: Aedes species.

21. Pathophysiology

22. Course in the Ward 11th to 19th Hospital day

23. arbovirus belonging to the Togaviridae Chikungunya Infection “kungunyala” - "contorted posture" or "bent posture – fever, rashes and arthalgia • Kiamba and Maitum in Sarangani • Villareal and Daram in Western Samar • Ma. Aurora in Aurora • Sindangan in Zamboanga del Norte • Sta. Rita in Samar • Concepcion in Romblon • Santiago in Agusan del Norte • Patnongon in Antique

24. “…reported cases involving symptomatic newborns with chikungunya infection in the days after birth, for whom the presumed mechanism of viral transmission was direct passage from maternal blood into the fetal circulation through placental breaches during labor. - Gerardin, P. Multidisciplinary Prospective Study of Mother-to-Child Chikungunya Virus Infections on the Island of La Re´union Chingkungunya infection during pregnancy • 50% (+) symptoms • 48% asymptomatic “…the time of greatest risk of transmission of Chikungunya virus from mother to fetus appears during birth if mother acquired the disease few days before delivery. - Shetty et al. Neonatal Chikungunya – a case report. Pediatric Oncall Source: Fritel et al.Chikungunya Virus Infection during Pregnancy, Réunion, France, 2006

25. Chingkungunya in Neonates Valamparampil et al. Clinical Profile of Chikungunya in Infants Haridas et al. Neonatal Chingkungunya – a case seires

26. “…complications of the disease can occur, including myocarditis, ocular disease (uveitis, retinitis), hepatitis, acute renal disease, severe bulbous lesions, and neuroinvasive disease, such as meningoencephalitis, Guillain-Barré syndrome, paresis, or palsies” - Staples, J. et al. Chikungunya Fever: An Epidemiological Review of a Re-Emerging Infectious Disease. Emerging Diseases. September 2009 Haridas et al. Neonatal Chingkungunya – a case seires

27. Diagnostics • Viral culture – gold standard • The detection of viral nucleic acid or of infectious virus in serum samples is useful during the initial viremic phase, at the onset of symptoms and normally for the following 5-10 days • IFA and ELISA are rapid and sensitive techniques for detection of CHIKV-specific antibodies, and can distinguish between IgG and IgM. IgM are detectable 2-3 days after the onset of symptoms and persist for several weeks, up to 3 months to 1 year

28. No specific antiviral treatment is available for chikungunya fever. • Treatment is for symptoms and can include rest, fluids, and use of analgesics and antipyretics. • Infected people should be protected from further mosquito exposure (staying indoors in areas with screens or under a mosquito net) during the first few days of the illness, so they do not contribute to the transmission cycle Treatment

29. Chikungunya is a self limiting illness with recovery being the rule • Few deaths have been reported • The morbidity and mortality of the disease may be avoided by the rational use of drugs and close monitoring of all infants.

30. Summary: At our present setting, there has been an emergence of Chikungunya outbreaks confirmed by The Department of Health (DOH) in several communities in 10 towns across our country Chikungunya represents a substantial risk for neonates born to viremic parturients that should be taken into account by clinicians and public health authorities in the event of a chikungunya outbreak. Careful history taking and physical examination and high index of suspicion remains to be the key in making the diagnosis