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Year : 2021  |  Volume : 22  |  Issue : 4  |  Page : 360-362

Chikungunya rickettsial coinfection with fatal outcome: A diagnostic dilemma

1 Department of Pediatric Dermatology, Indira Gandhi Institute of Child Health, Bengaluru, Karnataka, India
2 Department of Pediatrics, Indira Gandhi Institute of Child Health, Bengaluru, Karnataka, India

Date of Submission14-Sep-2020
Date of Decision13-Apr-2021
Date of Acceptance15-Apr-2021
Date of Web Publication01-Oct-2021

Correspondence Address:
Sahana M Srinivas
Department of Pediatric Dermatology, Indira Gandhi Institute of Child Health, Bengaluru, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijpd.ijpd_143_20

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Acute febrile illness caused by multiple infectious etiologies is not uncommon, especially in endemic countries like India. Recently, there has been increased mortality with chikungunya infection in children. There are several studies of coinfection of chikungunya with dengue, but coinfection with rickettsial infection is rare. We describe a 14-year-old boy presenting with chikungunya with probable rickettsial coinfection with a fatal outcome.

Keywords: Chikungunya, coinfection, fatal, rickettsial

How to cite this article:
Srinivas SM, Vijayasuriar S, Chandrasekaran P, Lakshmikantha KM. Chikungunya rickettsial coinfection with fatal outcome: A diagnostic dilemma. Indian J Paediatr Dermatol 2021;22:360-2

How to cite this URL:
Srinivas SM, Vijayasuriar S, Chandrasekaran P, Lakshmikantha KM. Chikungunya rickettsial coinfection with fatal outcome: A diagnostic dilemma. Indian J Paediatr Dermatol [serial online] 2021 [cited 2022 Jan 21];22:360-2. Available from: https://www.ijpd.in/text.asp?2021/22/4/360/327445

  Introduction Top

Chikungunya and rickettsial infections in children are highly prevalent in many parts of India.[1],[2] Although both the diseases are endemic in India, they are transmitted via different vectors making coinfections rare. Due to the multiple overlapping clinical features, rickettsial coinfection can be under diagnosed, leading to complications despite the availability of an effective antibiotic regimen. We report a case of chikungunya in a child with a fulminant course leading to multi-organ failure and death, probably attributable to the rickettsial coinfection.

  Case Report Top

A 14-year-old boy presented with a history of high-grade fever, joint pain along with vomiting and loose stools of 8 days, and skin lesions of 3 days duration. The skin lesions initially started over the trunk and extremities as areas of erythema which rapidly progressed to large bullae over the extremities. He was noted to have tachycardia (168/min), hypotension (blood pressure - 82/48 mm Hg), tachypnoea (40/min), and hypoxia (SpO2-89%). General examination showed mild icterus with no significant lymphadenopathy or hepatosplenomegaly. On cutaneous examination, there was reticulate purpura on the extremities along with multiple large bullae overlying areas of dusky erythema on the forearms, hip, thighs, and legs [Figure 1] and [Figure 2]. There was acral cyanosis with gangrenous changes of fingertips of both hands along with swollen interphalangeal and knee joints [Figure 3]. Exfoliation was noted on the face with hemorrhagic crusting on the lips [Figure 4]. In view of the above features, differential diagnoses of dengue-hemorrhagic fever, rickettsiosis, and chikungunya were considered. Laboratory investigations revealed leucocytosis (17,500/μL), thrombocytopenia (100,000/μL), increased C-reactive protein (>100), deranged liver and renal parameters (blood urea nitrogen: 80.1 mg/dl, serum creatinine: 2.91 mg/dl, total bilirubin: 5.17 mg/dl, conjugated bilirubin: 4.9 mg/dl, serum glutamic oxaloacetic transaminase: 253 U/L, serum glutamic pyruvic transaminase: 66 U/L, total protein: 3.5 g/dl, serum albumin: 2.1 g/dl), hyponatremia (128 mEq/dl) and hyperkalemia (5.8 mEq/dl). Chikungunya IgM was positive and Weil–Felix test was positive at 1:160 titer for OX-K. Due to lack of resources, immunofluorescence assay and polymerase chain reaction for confirming acute rickettsiosis could not be done. The diagnosis of chikungunya with probable rickettsial (scrub typhus) coinfection with multiorgan failure was made. He was managed with doxycycline, intravenous antibiotics, intravenous immunoglobulin, and supportive therapy. In view of the rapid worsening of clinical features, he was put on ventilatory, inotropic support, and peritoneal dialysis. Subsequently, he developed features of disseminated intravascular coagulation with hemorrhagic peritonitis, pleural effusion, and severe rhabdomyolysis (creatine phosphokinase: 34,840 mcg/L). Despite adequate treatment, child succumbed to death due to refractory sepsis and pulmonary hemorrhage.
Figure 1: Ill-defined areas of retiform purpura with overlying bullae on the right lower limb along with swelling of right knee joint

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Figure 2: Closer view of retiform purpura with overlying bullae on the left lower limb along with swelling of left knee joint

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Figure 3: Acrocyanosis, edema of the hand along with gangrenous fingertips

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Figure 4: Exfoliation seen on the face along with hemorrhagic crusting on the lips

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  Discussion Top

Recently several studies have documented the association of chikungunya with dengue in children. There are few reports of chikungunya rickettsial coinfection (scrub typhus, spotter fever) in adults.[3],[4] The overlapping clinical features in coinfection pose a diagnostic challenge for treating physicians.[5] The clinical presentation of chikungunya and dengue is similar in many aspects as both are vector-borne viral diseases and transmitted by Aedes mosquitoes. The association of chikungunya and rickettsial coinfection is interesting and rare as two different vectors are involved in the etiology. The classical presentation of chikungunya includes fever, polyarthralgia, and skin lesions which could be in the form of pigmentary changes in the centro-facial area, maculopapular rash, purpuric rash, acrocyanosis, desquamative lesions, intertriginous aphthous-like ulcers, or vesiculobullous rash, the latter being more common in infants.[6]

Although in the majority of affected children, chikungunya has a mild self-limiting course, there are reports of severe life-threatening manifestations with septic shock and multi-organ failure. Sharma et al., observed that age less than 1 year and 11–14 years were predictive of severe disease.[7] Atypical or severe manifestations are thought to be due to direct effect of the virus, host immunologic response, drug toxicity, or coinfection.[8] In addition to chikungunya IgM positivity, our child had a Weil-Felix test titer of 1:160 for OX-K. Although four-fold rise in titer could not be tested, the laboratory parameters and Weil–Felix test fulfilled Indian Academy of Pediatrics case definition for probable rickettsial (scrub typhus) infection.[9] Scrub typhus in children presents with fever, headache, myalgia, vomiting, abdominal pain, hepatosplenomegaly, and cutaneous manifestations that include eschar, maculopapular rash, retiform purpura, and petechiae. Rarely gangrene of digits, earlobes, or limbs may occur secondary to vasculitis and thrombosis.[10] Anti rickettsial antimicrobial therapy needs to be started early in the course of the disease and the mortality in untreated cases can be as high as 30%–35%.[2] Our child had established multi-organ failure at presentation and had retiform purpura, acrocyanosis, and gangrenous changes resulting from disseminated intravascular coagulation which could be a complication of either of the infections or coinfection.

  Conclusion Top

All the clinical and laboratory features mentioned in our case could be present in both rickettsial and chikungunya infections. Coinfection should always be considered in endemic areas, especially in postmonsoon season with multisystem involvement. They also have overlapping clinical symptoms often making them identify clinically. All patients presenting with acute febrile illness with multisystem involvement should be investigated for coinfection for initiating early and appropriate treatment and reduce mortality and morbidity. More cases should be reported to identify any clinical features that would be specific for rickettsial and chikungunya coinfection. This case highlights the need for a high degree of suspicion for coinfections in patients presenting with febrile illness with multiorgan failure especially in tropical countries.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Raghavendhar BS, Ray P, Ratagiri VH, Sharma BS, Kabra SK, Lodha R. Evaluation of chikungunya virus infection in children from India during 2009-2010: A cross sectional observational study. J Med Virol 2016;88:923-30.  Back to cited text no. 1
Thomas R, Puranik P, Kalal B, Britto C, Kamalesh S, Rego S, et al. Five-year analysis of rickettsial fevers in children in South India: Clinical manifestations and complications. J Infect Dev Ctries 2016;10:657-61.  Back to cited text no. 2
Premaratna R, Halambarachchige LP, Nanayakkara DM, Chandrasena TG, Rajapakse RP, Bandara NK, et al. Evidence of acute rickettsioses among patients presumed to have chikungunya fever during the chikungunya outbreak in Sri Lanka. Int J Infect Dis 2011;15:e871-3.  Back to cited text no. 3
Faruque LI, Zaman RU, Gurley ES, Massung RF, Alamgir AS, Galloway RL, et al. Prevalence and clinical presentation of Rickettsia, Coxiella, Leptospira, Bartonella and chikungunya virus infections among hospital-based febrile patients from December 2008 to November 2009 in Bangladesh. BMC Infect Dis 2017;17:141.  Back to cited text no. 4
Kamath V, Ganguly S, Avinash BL. A comparative study of concurrent infections of rickettsial infection, malaria, typhoid and chikungunya with dengue. APIK J Int Med 2019;7:120-6.  Back to cited text no. 5
  [Full text]  
Srinivas SM, Pradeep GCM. Congenital chikungunya infection presenting with extensive dystrophic calcinosis cutis. Indian J Dermatol Venereol Leprol 2020;86:693-6.  Back to cited text no. 6
[PUBMED]  [Full text]  
Sharma PK, Kumar M, Aggarwal GK, Kumar V, Srivastava RD, Sahani A, et al. Severe manifestations of chikungunya fever in children, India, 2016. Emerg Infect Dis 2018;24:1737-9.  Back to cited text no. 7
Ward CE, Chapman JI. Chikungunya in children: A clinical review. Pediatr Emerg Care 2018;34:510-5.  Back to cited text no. 8
Rathi N, Kulkarni A, Yewale V. For Indian academy of pediatrics guidelines on rickettsial diseases in children committee. IAP guidelines on rickettsial diseases in children. Indian Pediatr 2017;54:223-9.  Back to cited text no. 9
Rose W. Scrub typhus in children. Curr Med Issues 2017;15:90-4.  Back to cited text no. 10
  [Full text]  


  [Figure 1], [Figure 2], [Figure 3], [Figure 4]


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