Red Ear and Fever Associated with Immunoglobulin M Chikungunya Antibodies

Dear Editor, Chikungunya virus (CHIKV), which belongs to the genus Alphavirus, family Togaviridae, and order Martellivirales, is transmitted by Aedes aegypti and Aedes albopictus. The disease manifests as sudden-onset fever, rash, and polyarthritis or polyarthralgia. While various systemic and localized symptoms are recognized, erythematous auricle or “red ear” has emerged as an unusual cutaneous feature in some cases. We report five patients (three female, two male), aged 3 to 52 years, seen during the 2024 Chikungunya outbreak in Madhya Pradesh. All patients developed ear erythema 2–3 days after moderate-to-high fever onset in the convalescent phase of the disease. The ear erythema was localized to the helix and ear lobule, and there was associated pain and warmth in 3 patients [Figures 1 and 2]. Three patients exhibited pruritic centripetal maculopapular rash starting from forearms, mimicking drug-induced exanthem, whereas two had typical centrifugal viral rashes appearing 3–5 days post-fever. One febrile patient had scrotal erosions, along with a red ear. Four patients had generalized lymphadenopathy. Serology was positive for immunoglobulin M (IgM) chikungunya in all patients, while tests for dengue, measles, rubella, influenza, Epstein–Barr virus, and parvovirus B19 were negative. The presence of acute onset fever, severe arthralgia, as well as IgM positivity confirms a diagnosis of chikungunya. These findings were noted early, before arthritis development. Notably, ear erythema was seen across age groups and sexes.Figure 1: Twenty-two-year-old woman with chikungunya fever and erythematous pinnaFigure 2: Three-year-old male child with chikungunya fever and erythematous auricleErythema on one or both pinna with warmth, tenderness, or burning sensation can be considered a sign of chikungunya fever, and may be misdiagnosed as cellulitis, otitis, or allergy. Cutaneous manifestations of chikungunya include maculopapular rash on the trunk, limbs, and face; bullous lesions in infants and immunocompromised patients; inflammation of scars (scar phenomenon); palmar and facial pigmentation, especially on the nose and lip (“chik sign”).[1] Past studies have described a variety of skin findings, but seldom mentioned the “red ear” sign. Seetharam et al.[2], reported generalized maculopapular rash with islands of sparing in 52 children, starting 2–3 days after fever with sparing of mucosae. Some developed peeling akin to staphylococcal scalded skin syndrome. Inamadar et al.[3] found pigmentary changes (42%) to be most common, followed by maculopapular eruptions (33%) and aphthous-like ulcers (21%). Prashant et al.[4] noted transient erythematous rashes, genital ulcers, edema, and flare-ups of preexisting dermatoses. Bandopadhyay et al.[5] observed morbilliform rashes, xerosis, intertrigo, petechiae, mucosal involvement, and pruritus, but no ear erythema. However, select studies have reported the “red ear” as a significant clinical clue. Riyaz et al.[6] described localized pinna erythema and swelling mimicking Milian’s ear sign in 7 of 162 patients, typically 2–3 days after fever onset. Kumar et al.[7] found this in 5 of 112 cases (4.4%), along with rashes, vesicles, bullae, and the scar phenomenon. Javelle et al.[8] reported red ears in 127 of the 484 patients during a chikungunya outbreak, with some having swelling. These findings suggest that the “red ear” is more common than previously appreciated and may aid in early recognition. In contrast, ear pinna erythema has not been described in dengue. Hence, red, inflamed auricles during acute febrile illness favor chikungunya over dengue. The red ear typically appeared during the febrile phase, resolved spontaneously within a few days, and often preceded the onset of rash or arthralgia. Chikungunya induces systemic inflammation with cytokine-mediated vasodilation and increased localized blood flow, potentially explaining the auricular erythema. While this feature can aid diagnosis, differential diagnoses include cellulitis, otitis externa/media, erythromelalgia, or drug allergies. Diagnosis is confirmed by IgM/IgG enzyme-linked immunosorbent assay (ELISA) or reverse transcriptase–polymerase chain reaction (RT–PCR) for viral ribonucleic acid (RNA). Management remains symptomatic, as there is no specific antiviral therapy for chikungunya. To conclude, the identification of red ear or erythematous auricle as an early, distinctive cutaneous sign in chikungunya adds diagnostic value. Its presence early in the disease course, often preceding classical symptoms like rash or arthritis, may help diagnose chikungunya. Recognition of this underreported sign enhances clinical suspicion and supports timely diagnosis. Further observational studies on auricular erythema in viral exanthems are required to attribute red ear as a specific feature of chikungunya, as auricular erythema may be overlooked in several conditions. Declaration of patient consent The authors certify that they have obtained all appropriate patient/ parent consent forms. In the forms the patients/ parents have given their consent for their images and other clinical information to be reported in the journal. The patients/ parents 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. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest. Use of artificial intelligence (AI) Grammarly was used for language appropriation. No AI tool was used for content generation.