Abstract
After its first appearance in Kolkata (Calcutta) during 1963–1965, chikungunya occurred in epidemic form in India in 17 states and union territories. There were 13,90,322 cases suspected to be suffering from chikungunya in 2006, 59,535 in 2007 and 11,222 in 2008; in 2006, 2007 and 2008 there were 15,961, 7,837 and 262 samples, respectively, sent to the National Institute of Virology, Pune, and the National Institute of Communicable Disease, Delhi, for serological diagnosis. Of these, 2001, 1826 and 44, respectively, were confirmed as chikungunya. There were no deaths (data from the National Vector Borne Disease Control Programme, Government of India).
Introduction
There are usually no haemorrhagic or central nervous system complications as a result of chikungunya. However, in Asia it is associated with mild haemorrhagic features, but no shock. 1 In some cases, myocarditis and peripheral circulatory failure 2 have been seen. Encephalitis and manifestations of neurological involvement have occasionally been observed. 3 In chikungunya though rare, death rates of up to 0.4% have been recorded. However, in patients less than one year old, it may be as high as 2.8% and, similarly, over the age of 50 the death rate may increase. 1
The epidemic outbreaks of chikungunya that occurred in West Bengal in 2007 were documented; there were four suspected deaths 4 . One case was thoroughly investigated and this report presents the relevant findings of that patient.
Case history
A 38-year-old woman from a village, Baktarnagar, of the Burdwan District, was admitted to B R Singh Eastern Railway Hospital (BRSH) on 3 August 2007 with features of shock, cold clammy skin, stupor and confluent skin rashes all over the body. The provisional diagnosis on admission was dengue haemorrhagic shock syndrome or sepsis with peripheral circulatory failure. On enquiry, the patient's detailed history revealed that she suffered a fever for three days from 6 – 8 July with a temporary remission. The fever recurred on 22 July and was treated with paracetamol and broad-spectrum antibiotics without a response. She also had a history of joint pain and skin rash. On 25 July the patient presented with maelena which was continuing and on 31 July she had haematemesis. The patient was admitted to the Kalla Hospital of Eastern Coalfields Limited and was placed on symptomatic management. As her condition deteriorated, she was referred to Kolkata, and she was admitted to BRSH on 3 August. The patient was admitted to the intensive therapy unit and was placed on intensive symptomatic management with intravenous fluids, electrolytes, vasopressors and antibiotics. On admission, a tourniquet test was found to be positive and her platelet count was 7000/mm3. An immediate platelet transfusion was given. Although the patient was orientated, she was drowsy and suffered a protracted illness until her death. On investigation, chikungunya was strongly reactive and there was no evidence of dengue, malaria or other bacterial diseases. Hence, it was diagnosed as a case of chikungunya and, though rare, in this case the patient suffered a severe thrombocytopaenia, which was terminally complicated with hypertensive encephalopathy. The patient had a sudden cardiac arrest on 19 August and died at 2:00 hours.
Methods and results
Clinical examination
The pulse rate varied from 90/min – 124/min, blood pressure was 70/50 mmHg on admission; on 18 August she had hypertensive encephalopathy (220/120 mmHg), the liver and spleen were not palpable and there was no lymphadenopathy.
Routine examination of the blood
Haemoglobin was 8.1 g/dL; total leukocyte count 3500/µL; neutrophil 66%, lymphocyte 30%, monocyte 3%; platelet 7000/µL; P time 14.2s (control-12s); activated partial thromboplastin time 30s; fibrin degradation product 3013 ng/mL (<500 ng/mL).
Serological test
Chikungunya strongly reactive (HI) 1:640 titre; dengue immunoglobulin M negative; Widal negative; falciparum, antigen negative; anti double-stranded DNA negative; antinuclear antibody negative; C-reactive protein 10.8 mg/L; procalcitonin 0.6 µg/L (<0.4 µg/L); creatine phosphokinase 93 U/L.
Bacteriological examination
Bactec blood culture for aerobic, anaerobic and TB – negative; urine culture – no growth.
Ultrasound of abdomen
Right-sided small pleural effusion, no organomegaly; echocardiography ejection fraction 68%; chest X-ray, pneumonitis right lungs.
Electrolytes/liver function test/kidney function test
Serum K+ 2.71mEq/L; serum Na+ 130mEq/L; serum albumin 2.4 mg/dL; serum globulin 3.4 mg/dL; serum glutamic oxalo-acetic transaminase 109 IU/L; serum glutamic pyruvic transaminase 91 IU/L; albumin 2.7 mg/dL; bilirubin 1.6 mg/dL; increased blood urea and creatinine.
Cerebrospinal fluid
Protein 77 mg/dL; sugar 52 mg/dL; cell count – five cells/mm3; 100% lymphocyte.
Blood gas analysis
Oxygen pressure 64 mmHg; carbon dioxide pressure 44 mmHg.
Conclusion
Death due to chikungunya is extremely rare. We are not sure if the patient suffered from a new strain of the virus and feel that the possibility should be urgently investigated as this is the first reported death from chikungunya in India.