Original Article

Clinical Profile of Chikungunya in Infants

Joseph J Valamparampil, Shibi Chirakkarot, S. Letha, C. Jayakumar and K.M. Gopinathan
Department of Pediatrics, Institute of Child Health, Government Medical College, Kottayam, Kerala, India

ABSTRACT
Objective. To define the clinical manifestations of Chikungunya infection in infants.
Methods. The inclusion criteria was fever (defined as axillary temperature > 99.6 oF) with any one of the following features;
seizure, loose stools, peripheral cyanosis, skin manifestations or pedal edema in children less than one year. Details of
disease from onset of illness till admission were noted and a thorough clinical examination was done at the time of
admission. Daily follow-up was performed and the serial order of appearance of clinical features was noted till complete
recovery. The sera collected from patients after the 7th day of onset of fever was analyzed for specific chikungunya antibody
by IgM antibody capture enzyme linked immunosorbent assay (ELISA).
Results. Fifty six (56) infants were laboratory confirmed for chikungunya, consisting of 34 (60.71%) males and 22 (39.29%)
females. 4 (7.14%) infants were less than 1 month of age, 39 (69.64%) 2-6 months old and 13 (23.21%) 7-12 months old.
Fever was invariably present, but associated constitutional symptoms in infants consisted of lethargy or irritability and
excessive cry. The most characteristic feature of the infection in infants was acrocyanosis and symmetrical superficial
vesicobullous lesions were noted in most infants. Erythematous asymmetrical macules and patches were observed which
later progressed to morbiliform rashes. The face and oral cavity was spared in all observed patients.
Conclusion. An entirely different spectrum of disease is seen in infants with chikungunya as compared to older children who
need to be carefully observed for. The morbidity and mortality of the disease may be avoided by the rational use of drugs and
close monitoring of all infants. [Indian J Pediatr 2009; 76(2) :151-155] E-mail : drletha@yahoo.com
Key Words: Chikungunya; Skin manifestations; Infants; Vesiculobullous lesions; Acrocyanosis

Chikungunya an arboviral disease was first reported in

Tanzania during 1952-53. The chikungunya virus
(CHIKV) belongs to the genus alpha virus and family
Togaviridae.1 Etymologically, chikungunya owes its
origin to Kungunyala, a word from the Makoude
language of Tanzania meaning that which bends up,
which aptly conjures up the image of a patient who
adopts a stooped posture because of severe arthritis.1
The first reported outbreak of the disease in India was
in Calcutta city in 1963 and the last in Barsi in
Maharashtra in 1973. The virus reemerged in India in
December 2005.2 In southern India it was first noticed
in the state of Andrapradesh in February 2006 and then
spread to Tamilnadu in April 2006 and to Kerala in
May 2006. Kerala is witnessed a frightening outbreak of

Correspondence and Reprint requests : S. Letha, Professor of

Pediatrics, Department of Pediatrics, Institute of Child Health
Government Medical College, Kottayam, Kerala, India. Phone :
09447212539
[Received November 01, 2007; Accepted August 07, 2008]

Indian Journal of Pediatrics, Volume 76February, 2009

chikungunya particularly in the districts of Kottayam

and Pathanamthitta. Official records at the fever
containment cell show that 382,926 patients sought
treatment for suspected chikungunya in these districts
from January 1 st to July 5 th 2007. 2 However, other
available information shows that the actual number of
cases in the two districts during this period is not fewer
than double the official fig .2
The chikungunya virus is transmitted by mosquitoes
of the genus Aedis (mainly A. aegypti and A.albopictus).1
The mosquito, well adapted to life in urban settings,
breeds in clean puddles of standing water and
collections of water in artificial containers such as tin
cans, pots, rain barrels and discarded tyres. It is highly
susceptible to the virus, prefers to live close to people,
seeks a blood meal during day time and bites several
people in a short period for one meal.1 Most descriptions
of chikungunya fever are based on data obtained during
epidemics mostly in adults. Though various attempts
have been made to objectively evaluate the
manifestations of CHIKV infection in children, as to the
best of our knowledge, no proper documentation of the
same in infants is available in recent literature. We
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Joseph J. Valamparampil et al
report here the data accumulated on the vivid
manifestations of chikungunya infection in infants from
our experience during the present epidemic.

MATERIAL AND METHODS

Study Site
During the recent epidemic of chikungunya, many
babies from the area were admitted with fever and it
was found that many had a peculiar clinical pattern
which included fever and skin manifestations. IgM
done in the same cases was proved to be positive for
chikungunya and this made us think about a
prospective study of babies suspected of having
chikungunya. The study was done at the Institute of
Child Health at Kottayam district of Kerala state in
India. This region is famous for its high literacy rate
and its rubber plantations. The latex collecting
containers provide an exceptional breeding place for
the mosquitoes.

Subjects of the Study

The study was conducted at the Institute of Child
Health, Kottayam which is the lone pediatric tertiary care
centre pertaining to the region of central Kerala, from 5th
May 2007 to 5th July 2007 (2 months). The aim of the study
was to define the clinical manifestations of chikungunya
infection in infants and so ultimately only those cases
below one year which were CHIKV IgM were included
in the study. The inclusion criteria were fever (defined
as axillary temperature > 99.60 F) with any one of the
following features; seizure, loose stools, peripheral
cyanosis or skin manifestations. Details of disease
from onset of illness till admission were noted and a
thorough clinical examination was done at the time of
admission. Daily follow-up was performed and serial
order of appearance of clinical features was noted till
complete recovery.

RESULTS
Between May 2007 and July 2007 there occurred an
epidemic of chikungunya fever in the Kottayam and
Pathanamthitta districts of Kerala with its peak in June.
The case occurrence was unprecendently high among
infants also. The number of cases confirmed during the
study period at the Institute of Child Health was
considered as a representation of all the cases reported.
56 infants were laboratory confirmed for chikungunya,
consisting of 34 (60.71%) males and 22 (39.29%)
females. 4 (7.14%) infants were less than 1 month of
age, 39 (69.64%) 2-6 months old and 13 (23.21%) 7-12
months old.
The clinical features noticed in the chikungunya
confirmed infants were having fever, seizures, loose
stools, peripheral cyanosis and dermatological
manifestations
like
generalized
erythema,
maculopapular rash, vesiculobullous lesions and skin
peeling. Invariably in all cases fever was present and in
beginning 63% of infants had fever between 1010-1030F
and 37% between 1040-1060F. The present study noticed
that seizures occurred along with fever in 22 infants
(39.28%). The seizures were often atypical febrile
seizures; atypical in duration and frequency (8, 36.36%).
As many as 5 episodes of seizures were observed in 2
infants. Lumbar puncture and CSF study was done in
all patients with seizures and 100% of results were
normal. Peripheral cyanosis was noticed in 75% of
infants, with equal distribution amongst all age groups,
including neonates. Loose stools occurred in 41.07% of
patients with 75% of such having occurred on day 3 or
TABLE 1. Chronological Apperance of Clinical Features.

Laboratory Diagnosis
The sera collected from patients after the 7th day of onset
of fever was analysed for specific chikungunya antibody
by IgM antibody capture enzyme linked immunosorbent
assay (ELISA) using kits from National Institute of
Virology, Pune at the Department of Microbiology,
Government Medical College, Kottayam. Other laboratory
investigations like hemoglobin, leucocyte count, platelet
count and C-reactive protein were done in all patients.
Blood culture was done in all patients included in the
study and bleb culture was sent from all children with
vesiculobullous lesions. Lumbar puncture and CSF
analysis was done in all infants with seizure.

152

4 onset of fever. (Table 1. Chronology of clinical features

of Chikungunya in infants)
In 11 infants (19.64%) edema of lower extremities
was noted by third day of disease. Lethargy and poor
feeding was noted in 12 (21.42%) infants while

Indian Journal of Pediatrics, Volume 76February, 2009

Clinical Profile of Chikungunya in Infants

excessive cry and irritability occurred in 15 (26.79%)
infants at onset of the disease. Blood cultures and bleb
cultures from all the infants proved to be sterile.

DISCUSSION
The chikungunya epidemic epitomizes the classic
interaction between agent, host and environment. The
outbreak in our state may have assumed epidemic
proportions because the viral agent may have mutated,
the vector discovered new ways to spread or the host
lacked immunity to fight the disease. Economic
development does not protect populations from vectorborne diseases such as chikungunya. On the contrary,
development can favor outbreaks by profoundly
modifying the ecosystem, which may be the case in our
state.1
The reasons for the re-emergence of chikungunya in
the Indian subcontinent and for its unprecedented
incidence rate in the Indian Ocean region are unclear.
Plausible explanations include increased tourism,
chikungunya virus introduction into a new population,
and viral mutation. The incubation period can be 2-12
days but is usually 3-7 days. Silent CHIKV infections
do occur; but how commonly this happens is not yet
known. 3
A. Swaroop et al reported that the fever in
chikungunya is of sudden onset with chills and rigors
(> 1040F), subsides in 2-3 days and is associated with
conjunctivitis, anorexia, arthralgia and vomiting. 4 The
results of the present study confirm that fever is
invariably present, but associated constitutional
symptoms in infants consisted of lethargy (12, 21.43%)
or irritability and excessive cry (15, 26.78%). Joint
manifestations which are an inseparable entity in older
children and adults were absent in infants as per our
observation for which we unable to find out an
explanation. Seizures which have been described as an
association of the disease [Alladi Mohan et al] was
observed in 22 (39.29%) infants which roughly
correlates with those with fever greater than 104 0F
(37%).5 The interesting phenomenon noted by us was
that seizures where atypical in 36.36% (8 children)
while in general population the incidence of atypical
febrile seizures are only 20%.
Peripheral cyanosis without any hemodynamic
alteration was noted in 75% (42 children) in the study.
This sign is unique to the present study in that it has
never ever been mentioned in literature. These new
manifestations may be explained by the fact that the
African strains which are the cause of the present
epidemic exhibit wider sequence diversity and have
been shown to undergo genetic microevolutions even
Indian Journal of Pediatrics, Volume 76February, 2009

during the course of an epidemic.6,7 Hochedez et al in

their study noted that skin manifestations occurred in
77% of patients, no lesions were found on the face but
palms and soles were involved in a small number of
patients. 8 According to them erythema followed the
onset of fever by 1-2 days, lasted 3-7 days and
disappeared without scaling in all cases. 8 The present
observations revealed that at least one skin
manifestation was present in all the infants and two or
more manifestations were seen in 44% of infants.
Palms and soles were involved in 67.74% of cases
while facial involvement was rare, but not absent. The
first skin lesion to appear were generalized
erythematous rashes which developed abruptly during
first two days of fever only to subside within the next
two days. Next to appear was maculopapular rashes
in a centrifugal pattern on the second day after the onset
of fever and disappeared by the sixth day.
Sequentially vesicobullous lesions popped up
around the fourth day over the lower limb and spread to
involve the perineum, abdomen, chest and upper limb

Fig. 1. Infant with vesiculobulous lesions over lower limb

Fig. 2. Infant with chikungunya showing extensive peeling &

hyper & hypopigmentation

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Joseph J. Valamparampil et al

Fig. 3. Peeling lesions over lower limb

with exclusion of face and scalp noted in all cases. (Fig 1.

Infant with chikungunya infection showing
vesiculobullous lesions and hyperpigmentaion).
Except for three, all infants with vesiculobullous lesions
developed peeling of skin by sixth day. (Fig 2. Infant
with chikungunya with extensive peeling of skin, with
co-existing hypo-pigmentation and hyper pigmentation
of skin). Severe perianal involvement in the form of
erythema and peeling was noted in 55.17% of children
with bullous lesions. The skin lesions healed within six
days of appearance i.e., by the tenth day. In 39 (69.69%)
lesions healed leaving hyper pigmented scars while 13
(23.21%) had hypopigmented lesions. (Fig 3. Peeling
lesions over lower limb). Interestingly, in four patients
skin lesions left no scarring. Histopathologically,
pigmentary changes, maculopapular rash, lichenoid
rash, aphthous-like ulcers show lymphocytic
infiltration around dermal blood vessels.4 Since we did
not attempt skin biopsy in any of our children we are
unable to make any comments about the histopathology
of the skin lesions. The mechanism of skin lesion is also
not clear. Skin biopsy followed by immunocytochemistry studies may help in finding out the
mechanism of skin lesions in Chikungunya but the lack
of facilities limit us in doing so. Diarrhea was observed
in 23 (41%) of infants with onset on the third to fifth
day, but was never associated with blood in stools.
None of the babies developed dehydration and diarrhea
subsided by seventh to eight day. They were managed
with oral rehydration solution as per WHO protocol.
A. Swaroop et al described the presence of acral
edema in chikungunya infection in children. 4 In our
study we came across 11 infants (19.64%) with edema
of lower extremities by third to fourth day of illness. As
the study was conducted in a dengue fever endemic
area and co-circulation of both dengue and
chikungunya virus has been reported and the same
vector can sometimes transmit several arboviruses,
154

serology for dengue was done in the above cases.

Though previous reports suggest that antibody to
dengue virus and chikungunya virus were found in
0.4-4.3% of patients we couldnt document even a
single such case.4,5,9 The edema subsided spontaneously
by around seventh day. Pedal edema was observed in
many patients, the cause of which remains obscure as it
was not related to any cardiovascular, renal or hepatic
abnormalities. 9 Unlike dengue fever, hemorrhagic
manifestations are uncommon in chikungunya fever.
When present, they are mild and are more frequently
encountered in Asian compared with African patients.
These manifestations include epistaxis, bleeding from
gums, positive Hess test, subconjunctival bleed, and
petechial or purpuric rash. 5 In our study we came
across one case with purpura and echymosis
comprising 3.5% of total cases which is same as
reported elsewhere (M. Alladi et al)5. We had one case
with multiple aphthous like ulcers over the scrotum.
The current Central Kerala Chikungunya epidemic in
adults was easily distinguished by the presence of
freckle like hyper pigmentation over orofacial area in
the majority (unpublished data). But we had only one
child with such a manifestation. Manifestations like
meningoencephalitis and lymphadenopathy described
elsewhere were not found in the present study.
Chikungunya is a self limiting illness with recovery
being the rule. Few deaths have been reported.
Indiscriminate use of corticosteroids, nonsteroidal antiinflammatory drugs (NSAIDS) especially aspirin, and
antibiotics can contribute to thrombocytopenia,
gastrointestinal bleeding, nausea, vomiting and
gastritis. This may lead to dehydration, prerenal acute
renal failure, dyselectrotytemia and sometimes
hypoglycemia. These can indirectly contribute to the
mortality due to chikungunya fever.5 No deaths were noticed
in the present study which may be due to the rational use of
the above drugs and close monitoring of all infants.
Recently, Robillard et al reported details of the first 10 cases of
maternofetal chikungunya virus transmission and Lenglet
and colleagues reported 16 cases of new born babies
presenting symptoms of, and conformed diagnosis for,
neonatal chikungunya.9 The four neonates in the present
study concurred the disease after the twelfth day of life which
is equal to the longest incubation period there by ruling out
congenital chikungunya.
An entirely different spectrum of disease is seen in infants
with chikungunya as compared to older children who need to
be carefully observed for. The morbidity and mortality of the
disease may be avoided by the rational use of drugs and close
monitoring of all infants. A detailed investigation and
documentation of the epidemic is needed, with special focus
on mortality, complications, and virulence of the virus. We
need to better characterize the natural history of chikungunya.
We must ensure that the virus and the vector, possibly lurking
in the dark, do not catch us unawares again.
Indian Journal of Pediatrics, Volume 76February, 2009

Clinical Profile of Chikungunya in Infants

Acknowledgements
We are extremely thankful to Dr Jayalekha, Head of
Department of Microbiology for her guidance, and to Dr Jobin
Mathew and Dr Jacob George for their valuable support. We
express our sincere gratitude to all residents and staff of our
institution for their unflinching help.
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