CME REVIEW ARTICLE
Chikungunya in Children
A Clinical Review
Caleb E. Ward, MB, BChir* and Jennifer I. Chapman, MD†
Abstract: Chikungunya (CHIKV) is an emerging arboviral infection
with recent spikes in transmission in the Americas. Chikungunya is most
commonly transmitted by mosquitos, specifically Aedes aegypti and
Aedes albopictus. These mosquitoes are found throughout many parts
of the United States. The classic tetrad of symptoms for CHIKV is fever,
symmetric polyarthralgia, maculopapular rash, and nonpurulent conjunc-
Downloaded from http://journals.lww.com/pec-online by BhDMf5ePHKbH4TTImqenVLeEdd5NVDXpKbUwVoObA0Fnkyyl205ZLSiK42/xQdmT0EkdhHSpN+o= on 07/04/2018
tivitis. Although the majority (3 of 4) of infected people will be symp-
tomatic, the viral illness generally runs a benign course. Nevertheless,
when compared with infected adults, children more commonly have neu-
rological and dermatological symptoms and are less likely to have ar-
thralgia. The key differential diagnosis to consider is dengue, which
has greater immediate morbidity and which can cause coinfection. Local
health departments facilitate diagnostic testing, using either RNA poly-
merase chain reaction or antibody screening based on the timing of pre-
sentation. Management is supportive. The purpose of this review article
is to provide readers basic knowledge regarding the microbiology, epide-
miology, risk factors for transmission, and typical clinical presentation of
CHIKV. A practical approach to diagnosis and management of infected
children is provided.
Key Words: chikungunya, arbovirus, Aedes albopictus, Aedes aegypti
(Pediatr Emer Care 2018;34: 510–517)
TARGET AUDIENCE
This CME activity is intended for health care providers in
emergency department, urgent care, and hospital settings that ad-
minister medical care to children and adolescents.
LEARNING OBJECTIVES
After completion of this CME activity, the reader should be
better able to:
1. Evaluate and manage a child with suspected chikungunya
(CHIKV) infection.
2. Assess the epidemiology and transmission risk factors
for CHIKV.
3. Compare features that distinguish the two emerging arboviral
infections CHIKV and dengue.
*Pediatric Emergency Medicine Fellow (Ward), and †Assistant Professor of Pe-
diatrics (Chapman), Division of Pediatric Emergency Medicine, Department of
Pediatrics, Children's National Health System, George Washington University
School of Medicine and Health Sciences, Washington DC.
The authors, faculty, and staff in a position to control the content of this CME
activity and their spouses/life partners (if any) have disclosed that they have
no financial relationships with, or financial interest in, any commercial
organizations pertaining to this educational activity.
Reprints: Caleb Ward, MD, Division of Pediatric Emergency Medicine,
Department of Pediatrics, Children's National Health System, George
Washington University School of Medicine and Health Sciences, 111
Michigan Ave, NW, Washington DC 20010
(e‐mail: caward@childrensnational.org).
Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.
ISSN: 0749-5161
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A rthropod-borne viruses (hence arboviruses) are responsible
for some of the key emerging infectious diseases and signifi-
cant health problems the world faces today.1 Dengue virus is the
most common mosquito-transmitted arbovirus. In recent years, how-
ever, there have been spikes in transmission of CHIKV and Zika
viruses in the Americas. This article will focus on CHIKV and
providing essential background and practical knowledge for those
who might encounter this disease in a pediatric emergency setting.
There have been outbreaks of CHIKV in Africa and Asia ev-
ery 2 to 20 years for the latter half of the 20th century.2 The name
CHIKV was first used in 1953 during an outbreak of fever and
polyarthralgia in Tanganyika, eastern Africa. The Makonde trans-
lation for CHIKV is that which bends up, a reference to the crip-
pling arthralgia that many patients have.3 In the early part of the
21st century, there were multiple documented cases of CHIKV
in returning travelers throughout the United States and Europe,
and the Centers for Disease Control and Prevention (CDC) ad-
vised physicians to include CHIKV on their differential for fever
in a returning traveler.4 In December 2013, CHIKV gained inter-
national attention when the first local transmission in North
America occurred at Oyster Pond in St Martin.5
EPIDEMIOLOGY
By the end of 2014, the Pan American Health Organization
had reported almost 1 million cases of CHIKV in all 48
member-states.6 In the United States there were a total of 2811
cases reported to ArboNET in 2014 (including 12 autochthonous
cases, locally transmitted and not imported, from Florida). Forty-
five percent of the total national cases came from Florida and
New York.7 There were an additional 4710 cases from US terri-
tories, the vast majority of which were autochthonous cases in
Puerto Rico, the US Virgin Islands, and American Samoa.8 Provi-
sional CDC data for 2017 show 114 cases, all in travelers
returning to the United States (Fig. 1).9
MICROBIOLOGY, MODES OF TRANSMISSION,
AND RISK FACTORS
Chikungunya is a small (60–70 nm), spherical, enveloped vi-
rus.10 Chikungunya has a linear, positive sense, single-stranded
12 kb RNA genome.2 Other examples of the same genus of
alphaviruses include Eastern and Western equine encephalitis vi-
rus, Ross River virus, and Middleburg virus.2 Chikungunya, like
dengue and many other arboviruses, is capable of initiating a
sustained urban transmission cycle that relies on 2 species of mos-
quitoes: Aedes aegypti and Aedes albopictus (also known as the
tiger mosquito) with humans as the amplification host. These
are the same mosquito species associated with Zika transmission.
Aedes aegypti is found globally in the tropical, subtropical, and
parts of the temperate world.11 Aedes albopictus originated in
Asia but is now found in a global distribution.12 Within the
United States, 1 or both species are found in most states except
for the Pacific Northwest (Fig. 2).13 Returning travelers from
areas with high levels of mosquito activity are at risk for CHIKV.
The attack rate for CHIKV has been reported to be up to 60%
Pediatric Emergency Care • Volume 34, Number 7, July 2018
Pediatric Emergency Care • Volume 34, Number 7, July 2018 CHIKV in Children

FIGURE 1. States reporting CHIKV cases in 2017 (as of January 9, 2018).9

(aided by a population in Americas that has almost no immunity).
This is a higher attack rate than for dengue.14
Mosquitoes are the most common means of transmitting
CHIKV, but other modes of transmission are possible, including
blood-borne. During the 2014 Caribbean outbreak, there was a
high prevalence of CHIKV in donated blood samples (nucleic
acid amplification test samples peaked at 2.1% in one series),
but there have been no documented cases of CHIKV transmis-
sion due to transfusion.15 In the La Reunion outbreak, there
was one case of needle-stick transmitted disease.16
Transmission across the placenta during the first and second
trimester is possible although unusual, with rare cases of fetal in-
fection and miscarriage.17 Maternal infection within 1 week of
delivery, however, carries a high risk of vertical transmission and
potentially severe disease in the neonate. A single-center case se-
ries in Latin America tracked 7 women with peripartum infections
who delivered 8 babies: all newborns required intensive care unit
admissions, and there was a case fatality rate of 37.5%, with the
neonates having complications including respiratory distress, nec-
rotizing enterocolitis, meningoencephalitis, myocarditis, pericar-
ditis, edema, and bullous dermatitis.18 Paired serum testing of
mothers and newborns has shown that 81% of mothers transfer
antibodies to babies.19 There are conflicting statements on
whether CHIKV is transmitted in breast milk, as there are limited
data. The CDC states that there have been no confirmed cases of
infants acquiring CHIKV through breastfeeding and thus

FIGURE 2. Map of estimated ranges of Aedes aegypti and Aedes albopticus in the United States.13

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Ward and Chapman Pediatric Emergency Care • Volume 34, Number 7, July 2018

encourages women to continue to breastfeed even if they are
infected with CHIKV or live in an area with ongoing
virus transmission.20
CLINICAL SIGNS AND SYMPTOMS
In the United States where CHIKV is not yet endemic, a min-
imum case definition should be considered the acute onset of fever
and polyarthralgia in travelers recently returned from areas with
known virus transmission. The incubation time is 3 to 7 days
(range, 1–12 days), and the majority of those infected with CHIKV
become symptomatic (3 of 4 infected people in some estimates).
The disease is most typically characterized by fever higher than
39°C and a severe symmetric polyarthralgia that usually resolves
within 7 to 10 days (these 2 symptoms were present in 96% of con-
firmed cases in the La Reunion outbreak).21 The prevalence of
other symptoms in confirmed cases during this well-studied out-
break was as follows: headaches, 70%; nausea and vomiting,
63%; myalgia, 59%; exanthems, 48%; and a nonpurulent conjunc-
tivitis, 23%.21,22 Thus, in contrast to the minimum case definition,
the classic tetrad of symptoms is fever, symmetric polyarthralgia,
maculopapular rash, and nonpurulent conjunctivitis.
More serious and rare reported complications include en-
cephalitis, autoimmune neurological deficits (such as Guillain-
Barré and cranial nerve palsies), uveitis, retinitis, myocarditis,
hepatitis, nephritis, and death. Atypical or severe clinical manifes-
tations can be due to the direct effects of the virus, immunologic
response to the virus, drug toxicity, or coinfection with other dis-
eases. During the La Reunion epidemic, 0.3% of cases were de-
fined as atypically severe (defined as requiring organ support for
1 or more organ). The case fatality ratio is low (1:1000) with most
of these in very young or elderly patients or those with preexisting
medical conditions.23 In contrast to dengue, hemorrhagic compli-
cations are rare with CHIKV. Whereas symptoms typically last
less than 10 days, chronic symptoms, especially arthralgia, have
been reported for many months afterwards.
There are limited data on pediatric specific presentations of
CHIKV. Children have been noted to have a higher rate of asymp-
tomatic infection (up to 40%).24 Children may also exhibit a
broader range of dermatological manifestations (including bullous
rashes and pigment changes). Neurological manifestations are
more common in children, whereas myalgia and arthralgia are
less common. These age-related differences are summarized in
Table 1. One case series from India describes 56 infants less than
1 year old with acute illness and positive laboratory testing for
CHIKV immunoglobulin M (IgM).25 All patients had fever;
39% had seizures (all had cerebrospinal fluid studies that did not sug-
gest acute meningitis). Other features not typically described in adults
included cyanosis (75%) and dermatological manifestations includ-
ing generalized erythema, maculopapular rash, vesiculobullous le-
sions, and skin peeling. Joint findings were absent in this case
series. There were no fatalities. Caution should be taken in extrapolat-
ing these findings, as it is unclear whether these differences relate to
age-specific differences in the disease or strain-specific features of
the local epidemic. The potential long-term sequelae for perinatally
infected babies include a high risk for global developmental delay,
microcephaly, and cerebral palsy.26
Maternal infections do not appear to be more severe than in
nonpregnant adult women and do not appear to cause adverse out-
comes for the pregnancy. In one series of 1400 women with 658
infections (of which 15% were in the first trimester, 59% second
trimester, and 26% third trimester), rates of cesarean delivery,
hemorrhage, preterm births, stillbirths after 22 weeks, low birth
weight, congenital anomalies, and newborn admissions were all
similar for infected versus noninfected women.27
DIFFERENTIAL DIAGNOSES
The differential diagnoses for CHIKV vary based on place of
residence, travel history, and exposures. Dengue most closely
mimics CHIKV, with similar clinical features and transmission
by the same mosquito. These 2 viruses can also be coinfectants.
Exclusion of dengue virus infection is important, as proper clini-
cal management of dengue can improve outcomes. Per the
CDC, clinicians should consider dengue more likely when a pa-
tient has neutropenia, thrombocytopenia, hemorrhage, or shock.
Chikungunya is more likely when high fever, severe arthralgia, ar-
thritis, rash, and lymphopenia are present (Table 2). In addition to

TABLE 1. Chikungunya Clinical Presentation in Children Versus Adults24

Feature Children Adults

Fever
Skin manifestations
Mucocutaneous manifestations
Musculoskeletal manifestations
Chronic joint manifestations
Hemorrhagic manifestations
Neurological manifestations
Asymptomatic disease
Sudden onset, high grade (>38.9°C; duration, 1–8 d)
• Maculopapular rash (33%–60%)
• Pigmentary changes (42%)
• Bullous rash/skin blistering in 38%–48%
of infants <6 mo of age
• Oral ulcers (rare)
• Myalgia, arthralgia (30%–50%)
• Arthralgias/arthritis persistent for
2 years (5%–11%)
• Purpura, ecchymoses (10%)
• Severe bleeding from nose, gums, gut,
and shock (up to 19% in neonates)
• Headache (15%)
• Seizures, acute encephalopathy,
meningoencephalitis (14%–32%)
• 35%–40% (rare in neonates and infants)
• Maculopapular rash on trunk and limbs (35%–50%)
• Pigmentary changes (rare)
• Bullous rash/skin blistering or photosensitivity (rare)
• Oral ulcers (16%)
• Arthritis/arthralgia, symmetric, more commonly
affecting distal joints (87%–99%)
• Tenosynovitis (common)
• Back pain (more common)
• Myalgia (60%–93%)
• Arthralgias persistent or recurrent for 1 year in up to 57%
• Severe bleeding from nose, gums, gut, and shock (rare)
• Headache (40%–81%)
• Encephalopathy, meningoencephalitis, acute flaccid
paralysis, Guillain-Barré syndrome (<0.1%)
• 16%–27%

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Pediatric Emergency Care • Volume 34, Number 7, July 2018 CHIKV in Children

TABLE 2. Comparison Table of Laboratory Abnormalities Seen With CHIKV and Differential Diagnoses

Abnormality CHIKV (Alphavirus) Severe Dengue (Flavivirus) Zika (Flavivirus) Viral Illness
3
Leukopenia +++ Lymphopenia +++ (< 5000/mm ) Neutro > lympho Insufficient information Lymphocytic predominance
Anemia +/− Hemoconc (in severe) Insufficient information +/−
Low platelets + +++ (<100,000/mm3) Insufficient information +/−
Transaminitis + +/− Insufficient information +/−
Hyponatremia + (in severe) —
Coagulopathy +/− + (in severe) —
Diagnostic test Real-time RT-PCR or IgM RT-PCR or IgM RT-PCR or IgM Acute and convalescent titers
22,28 29
This table was constructed by authors from data in Refs. , and .
Note that severe dengue encompasses both dengue hemorrhagic fever and dengue shock syndrome.

dengue, other considerations include leptospirosis, malaria, rick-
ettsia, group A streptococcus, rubella, measles, parvovirus, en-
teroviruses, adenovirus, other alphavirus infections (eg, Mayaro,
Ross River, Barmah Forest, O'nyong-nyong, and Sindbis viruses),
postinfections arthritis, and rheumatologic conditions.
DIAGNOSTIC TESTING
The preliminary diagnosis of CHIKV should be based on the
patient's clinical features, places, and dates of travel, and activities.
Basic nonspecific laboratory abnormalities that may increase sus-
picion include leukopenia (usually a lymphopenia) (38%), throm-
bocytopenia (37%), elevated transaminases, and hypocalcemia
(39%).30 Laboratory diagnosis is done by testing serum or plasma
to detect virus, viral nucleic acid, or virus-specific IgM and neu-
tralizing antibodies. Because the clinical features of CHIKV and
dengue overlap, it is recommended to test for both infections. Note
however that antibodies for one arbovirus genus can cross-react
with heterologous antigens within the genus.31
The CDC testing algorithm includes CHIKV, Zika, and den-
gue viruses and is outlined in Figure 3.32 Diagnostic testing is cur-
rently available through state health departments and the CDC.
Practitioners should be familiar with the capabilities of their local
and state health departments. After the onset of illness, the virus
can be detected in blood and other tissues for 4 to 5 days. Viral
culture may detect virus in the first 3 days of illness. Because
CHIKV must be handled under biosafety level 3 conditions, this
test is not recommended in the CDC algorithm. Instead, CHIKV
viral-RNA can be identified using serum real-time reverse-
transcription polymerase chain reaction (RT-PCR) within 7 days
of symptom onset. Because viremia decreases over time, a nega-
tive test after 7 days should not rule out infection. If RT-PCR is
negative, clinicians sequentially test for serum IgM enzyme-
linked immunosorbent assay as long as the symptoms have been
present for at least 4 days. If both the viral RNA test (RT-PCR)
and the IgM antibody test are negative, the patient does not have
CHIKV. Beyond 7 days from symptom onset, the serum IgM test
is used alone. A negative IgM is sufficient to stop testing for

FIGURE 3. CDC testing algorithm for CHIKV, dengue, and Zika virus.32

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Ward and Chapman
CHIKV. If the serum IgM is positive, a confirmatory test using a
plaque-reducing neutralization test is performed to distinguish
which of the cross-reacting viruses is causing disease.
The best type of tube to collect blood samples in is a serum
separator (typically tiger/speckled-top). The blood should be
allowed to coagulate, and tubes should be spun to separate the
serum from the clot prior to shipping. If a red top is used (no ad-
ditive), the blood must be allowed to coagulate, the tube cen-
trifuged, and the serum drawn off into a clean tube prior to
shipping. Heparin (green top) and ethylenediaminetetraacetic
acid tubes (purple top) are unsuitable for CHIKV testing.
Chronic disease diagnosis is entirely dependent on IgG, with
no validated markers of chronicity or disease progression.
MANAGEMENT
The natural history of CHIKV is the resolution of acute
symptoms within 7 to 10 days. Treatment is primarily symptom-
atic, with no specific antiviral therapy recommended. Providers
should assess hydration and hemodynamic status and provide
supportive care as needed. Acetaminophen can be used for fever
and pain control. If further analgesics are required, consider judi-
cious use of narcotics. Some authors warn against indiscriminate
use of corticosteroids and nonsteroidal anti-inflammatory drugs
(NSAIDs) (especially aspirin) owing to the risk of platelet dys-
function increasing the risk for clinically significant hemorrhage.
In addition, the overlap in symptoms with dengue infection leads
to the CDC recommending against the use of NSAIDs because of
the risk of hemorrhage with dengue infections.
Chikungunya virus disease is a nationally notifiable condi-
tion, meaning that health care providers should report suspected
CHIKV cases to their state or local health departments to facilitate
diagnosis and mitigate the risk of local transmission. To decrease
autochthonous transmission, patients should be counseled to stay
indoors and avoid mosquito bites during the first week when they
are most likely to be viremic.
Some patients might have relapse of rheumatologic symp-
toms (eg, polyarthralgia, polyarthritis, and tenosynovitis) in the
months after acute illness. Persistent joint pain may benefit from
the use of NSAIDs, corticosteroids, or physiotherapy. Chronic ar-
thralgia has been treated with a range of medications in small trials
in both humans and animals, with mixed results. Referral to a pe-
diatric rheumatologist would be appropriate in these cases. A
number of candidate vaccines for CHIKV are currently in the pre-
clinical and clinical stages of development.33,34
CONCLUSIONS
Chikungunya has been endemic in Africa and Asia since at
least the 1950s. Year 2013 marked the beginning of local spread
of cases within the Americas, with more than 1 million cases docu-
mented in 2014. Chikungunya usually consists of fever and arthral-
gia for 7 to 10 days. Compared with adult cases, pediatric patients
are more likely to have a range of acute neurological and dermato-
logical manifestations, while being less likely to develop subacute
or chronic joint problems. The treatment remains largely support-
ive. Testing for CHIKV exists through state health departments
and the CDC including RNA and IgM. Chikungunya is a notifiable
disease in the United States. Any viremic traveler with CHIKV who
returns to an area in the United States with A. albopictus or aegypti
mosquitoes could initiate a local outbreak. There is therefore a need
to establish local processes for workup and management of such
cases. Emerging infection diseases such as CHIKV require clear
lines of communication between emergency department and in-
fectious disease specialists, along with pediatricians in the com-
munity as well as local and state health departments.
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Pediatric Emergency Care • Volume 34, Number 7, July 2018
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