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Indian Pediatr 2017;54: 249 |
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Neurological Manifestations of Chikungunya in
Children
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Amitabh Singh and *Rahul Jain
Department of Pediatrics, Chacha Nehru Bal Chikitsalaya,
New Delhi, India.
Email:
[email protected]
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Chikungunya disease re-emerged in India in October 2005 after nearly 32
years of quiescence, and has shown cyclical trend since then [1]. The
city of Delhi experienced an outbreak of chikungunya fever from August
to October 2016. Chikungunya virus is considered to cause a
self-limiting benign illness characterized by fever, rash and arthralgia
in children. However, unusual neurological manifestations, including
seizures, altered level of consciousness, blindness due to retrobulbar
neuritis and acute flaccid paralysis are known to occur [2]. As with
other epidemics, the unusual manifestation of disease are better
recognized during the outbreaks.
We observed five children of Chikungunya with
neurological involvement (out of total 48 admitted patients) in the
present epidemic. The diagnosis of chikungunya was confirmed by
real-time PCR assay in four children, and by IgM ELISA in one child. All
children had abrupt onset of high-grade fever, followed by neurological
signs and symptoms. One child succumbed to meningoencephalitis within 6
hours of presentation, and had concomitant hepatic involvement. Two
children aged 6 and 8 years presented with fever, seizure and altered
sensorium with thrombocytopenia. CSF examination was suggestive of viral
meningoencephalitis and attempts to isolate chikungunya from CSF was
negative. Both showed complete recovery within 3-4 days of admission.
Two children (aged 6 and 10 years) presented with neuro-psychiatric
behavioral disturbances in form of hyperactivity, insomnia, aggressive
behavior, hallucination, disorientation, and loss of social inhibitions,
with onset within first week of fever. One of them presented on day 4 of
illness and showed complete recovery within 3-4 days of presentation.
The second child (IgM ELISA positive) presented late and had persistent
behavioral problem. Work-up for other etiologies like dengue and
autoimmune encephalitis (Anti-NMDAR antibody) were normal. Neuroimaging
and EEG were also non-contributory. He received low dose risperidone
following which his sleep and aggressive behavior improved but other
psychotic symptoms persisted during follow-up at four weeks.
Neurotropic nature of chikungunya resulting in
neurological complication is infrequently reported during outbreaks [3].
There is no clear evidence to suggest whether these manifestations are
due to persistence of virus in central nervous system or due to abnormal
immune response [3]. We tried to isolate Chikungunya virus from CSF in
two patients but results were negative.
Chikungunya infection should be considered as a
differential diagnosis in children presenting with fever and
neurological symptoms during epidemics. The outcome is guarded as
mortality can occur in acute phase and neuro-psychiatric morbidity may
persist.
References
1. Mohan A, Kiran D, Manohar IC, Kumar DP.
Epidemiology, clinical manifestations, and diagnosis of chikungunya
fever: lessons learned from the re-emerging epidemic. Indian J Dermatol.
2010;55:54-63.
2. Sebastian MR, Lodha R, Kabra SK. Chikungunya
infection in children. Indian J Pediatr. 2009;76:185-9.
3. Lewthwaite P, Vasanthapuram R, Osborne JC, Begum A, Plank JL,
Shankar MV, et al. Chikungunya virus and central nervous system
infections in children, India. Emerg Infect Dis. 2009;15:329-31.
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