Mucocutaneous Manifestations of Chikungunya Fever in a Recent Outbreak from a Tertiary Care Center in Punjab, India: An Observational Study

Chikungunya fever is an acute febrile illness caused by chikungunya virus transmitted to humans by the bite of infected mosquitos.[1] Since 1963, it has re-emerged in different parts of India.[2] Punjab saw a sudden rise in chikungunya cases from July to October 2023 with reports of 2034 suspected chikungunya cases by September 17, 2023, compared to 644 in 2021 and 1087 in 2022.[3] The rise in chikungunya cases in this non-endemic area followed this year’s severe floods providing a breeding ground for vector mosquitoes. This highlights the need for an integrated approach to vector surveillance and control of chikungunya outbreak.[4] Chikungunya fever is characterized by high fever, maculopapular rash and polyarthritis/arthralgia.[5] We conducted a prospective, cross-sectional study at a tertiary care center in this district in Punjab, where chikungunya cases are at record high. We included 79 suspected cases of chikungunya fever who visited the Dermatology OPD. Regular follow-up was conducted and IgM capture ELISA specific for chikungunya virus was performed for all cases. Additional investigations such as complete hemogram, ESR, CRP, dengue serology, and malaria parasite tests were conducted as needed. The age and gender distribution of cases is depicted in Table 1. Table 1 - Age and Gender Distribution of Cases Characteristics Frequency Percentage Age (years) <10 7 8.86 10–20 7 8.86 20–30 13 16.45 30–40 20 25.31 40–50 18 22.78 50–60 6 7.59 60–70 5 6.32 >70 3 3.79 Gender Males 37 46.83 Females 42 53.17 The different cutaneous manifestations observed in this study along with the time gap from onset of fever are presented in Table 2. Most patients developed cutaneous lesions within 7 days of the acute phase, while 7.86% had lesions persisting for 1 month or longer. Additionally, 20.25% of patients exhibited more than one type of lesion. Table 2 - Cutaneous Manifestations of Chikungunya Fever No. Clinical Features Number of Patients Time Gap from Onset of Fever (Days) 1 Rash 32 (40.5%) 2–10 1a Maculopapular/Macular rash 17/7 (30.37%) 2–7 1b Pityriasis rosea like rash 2 7–10 1c Psoriasiform Rash 2 5 1d Seborrheic dermatitis like rash 3 4–7 1e Purpuric rash 1 6 2 Pruritus 18 (22.7%) 4–30 2a Generalized pruritus 16 (20.2%) 2b Palmar pruritus 2 3 Palmar erythema 3 (3.79 %) 4–6 4 Oedema 14 (17.7%) 4a Oedema face 10 2–5 4b Oedema hands and feet 4 2–7 5 Hyperpigmentation 35 (44.3%) 5a Chik’s sign 15 5–30 5b Centrofacial hyperpigmentation 8 5–20 5c Freckles 2 7–10 5d Exacerbation of melasma 2 9–30 5e Full body hyperpigmentation 2 5–10 5f Hyperpigmetation of palms 4 5–30 5g Flexural Hyperpigmentation 2 10–15 6 Ulcers 12 (15.1%) 6a Scrotal ulcer 2 3–9 6b Flexural ulcer 8 2–5 6c Oral aphthous ulcers 2 4–6 7 Vasculitis 1 8 8 Urticaria 3 1–6 9 Ear sign 2 6–7 10 Vesicles on striae 1 15 11 Desquamation of skin of palms 2 12–30 12 Blisters hands & feet 1 10 The most common skin manifestation was hyperpigmentation of face, palms, or diffuse pigmentation of full body. The various patterns of facial hyperpigmentation seen in our study are depicted in Figure 1. Generalized hyperpigmentation involving full body was observed in two IgM ELISA positive infants [Figure 2]. There was spontaneous resolution of hyperpigmentation on follow-up of one child after one month while other child was lost to follow-up. Hyperpigmentation is a well-documented occurrence in chikungunya fever across multiple studies.[6] The distinctive brownish pigmentation on the nose, known as the “chik sign,” serves as a diagnostic indicator.[6] Other patterns include macular, melasma-like, freckle-like, slate grey, flagellate-like, and Addisonian-type pigmentation. Hyperpigmentation may be due to increased melanin retention or dispersion induced by the virus.[7] In our study, facial pigmentation showed significant improvement within 4–6 weeks of treatment [Figure 3].Figure 1: Various patterns of facial hyperpigmentation (a) Chik’s sign (b) Centrofacial macular pigmentation (c) Freckle like pigmentation (d) Palmar pigmentation.Figure 2: Diffuse generalized slate grey pigmentation in an infant with Chikungunya fever.Figure 3: (a–c) Facial and neck hyperpigmentation in acute phase of fever. (d–f) Post treatment images of hyperpigmentation after 1 month.The second most common skin manifestation was an erythematous maculopapular and macular rash observed in 24 (30.38%) patients, primarily appearing on the upper limbs, face, lower limbs, and trunk. Hochedz et al.[8] reported facial sparing, which is in contrast to the findings of our study. Rash caused intense itching in nearly half of our patients. Table 3 illustrates the variation of rash and pruritus in chikungunya fever in different studies. The viral rash results from both direct viral cytopathic effect and immunological factors.[6] In the present study, prior skin dermatosis did not worsen, but some patients developed psoriasiform rash, seborrheic dermatitis-like rash, and pityriasis rosea during the acute illness phase [Figure 4]. The virus may act as a superantigen, triggering immune responses through both innate and acquired pathways, leading to diverse clinical symptoms even in individuals not typically susceptible to the virus.[9] Table 3 - Comparison of Various Indian Studies on Mucocutaneous Manifestations of Chikungunya Fever Our Study 2023 Patiala, Punjab 2016 Chopra et al.[15] South east Rajasthan 2016 Kumar et al.[12] Karnataka 2008 Bhat et al.[13] Bijapur, Karnataka 2006 Inamadar et al.[7] Calicut, Kerala 2009 Riyaz et al.[6] Hyderabad 2006 Prashant et al.[10] West Bengal 2008 Bandyopadhyay et al.[14] Number of case 79 22 112 75 145 162 115 26 M:F 0.8:1 1.4:1 1.2:1 1:1 1.8:1 0.63:1 1.3:1 1:1 Most common cutaneous manifestation Hyperpigmentation Hyperpigmentation Maculopapular rash Maculopapular rash Hyperpigmentation Erythematous rash Maculopapular rash Maculopapular rash Hyperpigmentation (%) 44.3 82 39.2 16 42 38.2 10.43 11.53 Macular/Maculopapular rash (%) 30.37 72.7 53.5 52 33 58 35.65 80.76 Apthae like ulcers (%) 15.1 18 (4/22) 16 22.66 22.06 17.8 23.47 3.8 (1/26) Figure 4: (a) Seborrheic dermatitis like rash in an elderly male on day 5 of chikungunya fever (b) Pityriasis rosea like rash in a female on day 8 of chikungunya fever.Like previous studies, aphthae-like lesions (intertriginous aphthae > oral aphthae) were found in 15.1% of patients in our study. Inamadar et al.[7] and Prashant et al.[10] also noted a higher occurrence of intertriginous/genital ulcers compared to oral aphthae. The frequent development of groin aphthous ulcers in young men is notable. These ulcers, characterized by pain, discrete presentation, and irregular margins, appeared suddenly on day 2/3 of fever and resolved within 7–10 days with treatment. Bacterial cultures and KOH mounts from these ulcers were negative. The presence of perivascular lymphocytic infiltration and vascular endothelial alterations suggests virus-triggered vasculitis [Figure 5].[7]Figure 5: Intertriginous aphthae like ulcers (a) groins on day 4 of fever. (b and c) healing groin ulcers on day 10 of fever (d) inframammary aphthous ulcers on day 5.Blisters and vesicles on hands were seen in one patient and one full term primigravida female patient developed blisters limited to striae 6 days after chikungunya fever which resolved within few days. The vesiculobullous lesions can be attributed to epidermal injury inflicted by the virus.[7] Facial edema/puffiness, which is a manifestation of acute phase of chikungunya fever, was observed in 12.6% of cases.[11] An adult patient developed leukocytoclastic vasculitis on day 8 of fever, which responded to short course of systemic steroids. Skin biopsy was refused by the patient. No nail changes were noted in this study. All patients were treated symptomatically, and the response to conservative management was good. There were no long-term sequelae from cutaneous manifestations, but the only exception was prolonged hyperpigmentation of face in few cases. Table 3 gives a comparison of mucocutaneous manifestations of chikungunya fever in various studies done in India. Table 4 displays a comparison of the characteristics of three major cutaneous manifestations of Chikungunya Fever as observed in previous Indian studies. Table 4 - Comparison of Characteristics of Three Major Cutaneous Manifestations of Chikungunya Fever Seen in Indian Studies. Our Study 2023 Patiala, Punjab 2016 Chopra et al. [15] South east Rajasthan 2016 Kumar et al. [12] Karnataka 2008 Bhat et al. [13] Karnataka 2006 Inamadar et al. [7] Kerala 2009 Riyaz et al. [6] Hyderabad 2006 Prashant et al. [10] West Bengal 2008 Bandyopadhyay et al. [14] MC sites of hyperpigmentation a. Nose, b. Centrofacial areac. Palmsd. Trunk Nose a) Noseb) Facec) Trunkd) Mucosal Only face FacePinnaExtremities a) Noseb) Trunkc) Extremities Nose & cheeks Not mentioned MC pattern of hyperpigmentation a. Macularb. Freckle likec. Melasma liked. Slate grey like a) Macularb) Melasma‑likec) Lichen planus pigmentosus‑like over neck and flexures,d) Periorbital hypermelanosise) Irregular and flagellatepatterns on the trunke) Addisonian type of palmar pigmentation. a) Diffuse hyperpigmentation of faceb) Centrofacial a) Freckle likeb) Slate grey like on face, pinna, extremities, a) Macularb) Melasma-like over the facec) Periorbital melanosisd) Irregular and flagellate patterns on the trunk, extremities, and abdomene) Addisonian type of palmar pigmentation. Macules Not mentioned MC type of rash MaculopapularMacular Maculopapular rash Maculopapular rashFacial flushingMacular rash Maculopapular rash a) Macular rashb) Maculopapular rash Maculopapular rash Maculopapular rash MC site of rash Upper limbsFaceLower limbstrunk Generalized Generalized Generalized Generalized Trunk & extremities Upper extremitiesFaceTrunk Association of pruritus with rash 45.8%intensity: severe ND 77.6%severe NDmild NDmild to moderate 70% 20%mild 19.2% MC site of Aphthous like ulcers Groin 6Scrotum 2Inframammary 2Oral 2 Both Axillae & groins 4 Oral 11Genital 5Axillary 2 Oral 12Axillae 3Groin 2 Scrotum, penis, groin, and perianal 31Axillae 2Oral 1 Oral 22Penoscrotal 2 Scrotum & labia majora 27Oral 7 Oral 1Intertriginous 0 MC = most common, ND = not determined. To conclude, a myriad of cutaneous manifestations were observed in the recent outbreak of chikungunya fever in this part of the country. An important finding was the good response of hyperpigmentation in chikungunya to early treatment with mild depigmenting creams and sunscreen. Unlike Dengue fever, hemorrhagic manifestations were rarely seen in chikungunya fever. Facial edema in the early phase of chikungunya fever was seen in this study. As chikungunya fever extends to non-endemic regions of the country, it becomes crucial to recognize and treat these conditions early by being aware of myriad of cutaneous manifestations of this disease.