Transcript Haridas et al. Neonatal Chingkungunya – a case seires

Chikungunya in a
Neonate
Presenter: Cherry May V. Villar, M.D.
First Year Resident
Adviser: Renee Joy P. Neri, M.D.
Ambulatory Pediatrics, Consultant
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
General Data:
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Z.D.
16 day old, male
Filipino, Catholic
Meycauyan, Bulacan
Informant: mother
Reliability: 90%
Chief complaint: fever
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 OBGYNE
• 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.
• (+) 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
• 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.
• 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.
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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.
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(+) 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.
Family History
(+) hypertension – paternal side
(-) DM, PTB, CA, epilepsy
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.
Nutritional History
• 1-2 ounces of milk formula (Enfalac) every
2 to 3 hours.
Immunization History
• BCG – 1
• Hepatitis B -1
Growth & Developmental History
• Lies in flexed position, head lags,
preference to human face (+) Dolls eye
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
Physical Examination
• Asleep but arousable, not in distress
BP 80/50
CR 142
RR 36
T: 38.1 C
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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
• 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
Neurologic PE
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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
Salient Features
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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.
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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
Differential Diagnosis
Hyperbilirubinemia
secondary to ABO
incompatibility
Neonatal Sepsis
Inborn error of
metabolism/Metabolic
Encephalopathy
Working Impression
Full Term, male, Neonatal Chikungunya
infection
Health care associated infection
Epidemiology
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Chikungunya virus (CHIKV)
mosquito-transmitted alphavirus
first isolated in Tanzania in 1952
main vectors: Aedes species.
Global
• identified in nearly 40 countries
• periodic outbreaks in Asia and Africa since the 1960s
Philippine Pediatric Society
• 10 cases in 50 year period
Philippine Childrens Medical Center
• No cases reported
Pathophysiology
Course in the Ward
11th to 19th
Hospital day
8th to 10th
Hospital day
2nd to 4th
Hospital day
First
hospital day
Chikungunya Infection
arbovirus belonging to the Togaviridae
“kungunyala” - "contorted posture" or "bent
posture – fever, rashes and arthalgia
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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
Chingkungunya infection during pregnancy
•50% (+) symptoms
•48% asymptomatic
Maternal signs Percentage
and symptoms
fever
62
Arthralgia
93
Headache
54
Edema
54
Diarrhea
12
Apthae
9.6
epistaxis
9
rash
76
“…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
Source: Fritel et al.Chikungunya Virus Infection during
Pregnancy, Réunion, France, 2006
“…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
Chingkungunya in Neonates
signs and
symptoms
Percentage
signs and
symptoms
fever
Percentage
92
Peripheral
cyanosis
75
rash
76
Rash
64
fever
63
35
Loose stools
41
Blotchy
erythema
19.6
seizures
35
Respiratory
distress
28
edema
14
Skin
desquamation
14
edema
Poor feeding
seizures
37
lethargy
21.42
epistaxis
9
Valamparampil et al. Clinical Profile of
Chikungunya in Infants
71.4
Haridas et al. Neonatal Chingkungunya – a
case seires
“…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
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 23 days after the onset of symptoms and persist for
several weeks, up to 3 months to 1 year
Treatment
• 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
• 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.
Summary:
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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