Home            Past Issues            About IP            About IAP           Author Information            Subscription            Advertisement              Search  

   
Case Report

Indian Pediatr 2012;49: 238-240

Neurodevelopmental Outcome of Neonates with Vertically Transmitted Chikungunya Fever with Encephalopathy


S Shenoy and GCM Pradeep

From the Department of Paediatrics, MS Ramaiah Medical College,Bangalore, India.

Correspondence to: Dr S Shenoy, Department of Pediatrics, MS Ramaiah Medical College,
MSR Nagar, MSRIT Post, Bangalore, India.
Email: [email protected]

Received: September 04, 2010;
Initial review: October 25, 2010;
Accepted: January 24, 2011.

 


Neurodevelopmental follow-up of neonates with vertically transmitted Chikungunya fever has been infrequently reported. We herein report neurodevelopment follow up of two such babies at 3 year of age.

Key words: Chikungunya, Newborn, Neurodevelopment


Although there are few anecdotal reports on the vertical transmission of the virus from the mother to the newborn [1-3], there are no reports on follow up of these children. We describe the follow up of two such newborns with encephalopathy at 3years.

Case Report

Case 1: A 5 day old male, born at term by caesarian section with birth weight of 3.5 kg and normal apgar scores was referred with altered sensorium and convulsive apnea. On examination, he had features of encephalopathy. Mother had history of fever with joint pain few days prior to delivery. Initial work up for seizures was normal (blood glucose, serum electrolytes, CSF examination and CT scan). Septicemia was ruled out by relevant investigations (complete blood count, peripheral smear, CSF examination and blood culture sensitivity). He had hypoproteinemia and lymphedema during the hospital stay. At 1week of life, he was noticed to have hyperpigmentation over nose, face and groin. In view of maternal fever and joint pain and endemicity of the disease, baby’s and maternal blood was sent for RT PCR for chikungunya, which was positive. Hence, a final diagnosis of vertical transmission of chikungunya was considered. The baby was treated symptomatically and was discharged on direct breast feeding. The hyperpigmentation lasted two months and gradually settled.

During his initial follow up, he was found to have hypertonia for which he was advised early intervention and stimulation. He subsequently developed spastic diplegia. He also has a seizure disorder starting at 11months for which he is on 2 anticonvulsants, CT scan and EEG done at one and a half years were normal. His IQ assessment done by the Binet Kamat test of intelligence showed a score of 62 and his category of IQ was borderline. His social intelligence was age appropriate. His meaningful memory and visuo-motor skills were adequate whereas his language, nonmeaningful memory, conceptual thinking, nonverbal and numerical reasoning were inadequate. He was also found to be hyperactive for which he is on appropriate intervention.

Case 2: A 5-day-old female baby born at term with birth weight of 2.8 kg to HBsAg positive mother by caesarian section was referred with repeated convulsive apnea and lethargy since 2 days. Mother had history of high grade fever with joint pain just prior to delivery. On admission the baby had features of encephalopathy. Initial workup for seizures was normal (blood glucose and electrolytes, CSF, CT scan and EEG). Work up for septicemia was also negative. Baby was found to have hypoproteinemia and lymphedema. Baby had to be ventilated on day 4 of admission in view of repeated convulsive apnea and poor respiratory efforts. Supportive treatment was given baby and was discharged on full feeds. Babies and maternal serum for RT PCR for chikungunya positive. On day 10, baby was noticed to have perioral, limb and abdominal hyperpigmentation. On follow up, she was found to be hypotonic for which she was started on early intervention and stimulation. At 6-months of age, she was found to have poor visual regard. VEP was done and was found to be abnormal with poor NPN complexes suggestive of primary optic atrophy. BAER study done at one year of age was normal. She is presently 3 yrs and has hypotonic cerebral palsy with mental retardation. Her IQ assessment done by Binet Kamat test of Intelligence gave a score of 58 and the category of IQ was poor. Her social intelligence, visuo-motor skills, numerical reasoning and language skills were poor. Her conceptual thinking, non verbal reasoning and meaningful memory were also inadequate whereas her non meaningful memory was adequate.

Discussion

We found that both the newborns that developed chikungunya encephalopathy had persistent disabilities which included cerebral palsy, visual impairment, seizure disorder and behavioral problems. Chikungunya virus infection was first reported to affect the nervous system in the 1960s[4]. The neurotropism of this virus has not been completely studied. The ability of the virus to invade and replicate in the brain parenchyma has not been consistently proven by animal studies. Experimental studies have shown that the virus disseminates to the central nervous system in severe cases, where it specifically targets the choroids plexus and the leptomeninges [5]. In a study done in adults in Nagpur district of Maharashtra, it was found that 16.3% had neurological complications which included encephalitis, myelopathy, peripheral neuropathy, myeloneuropathy and myopathy. RT-PCR and real time PCR was positive in the CSF in 16% and 18%, respectively [6]. Another report [1]from the Reunion Island showed that 4 out of the 9 neonates with encephalopathy developed persistent disabilities, which included cerebral palsy with blindness and ataxia in one and three had ocular and behavioral or postural deficiencies. However, the outcome of the neurological symptoms was generally good in adults [7].

In conclusion, encephalopathy appears to be the most common clinical presentation of the disease during mother to child transmission and can be associated with long term disability. Hence, newborns with vertical transmission of chikungunya need a close follow up for abnormal neurodevelopmental outcome.

Contributors: Both authors contributed to review of literature and drafting the manuscript.

Funding: None; Competing interests: None stated.

References

1. Girardin P, Barau G, Michault A, Bintner M, Randrianaivo H, Choker G, et al. Multidisciplinary prospective study of mother to child chikungunya virus infections on the island of La Reunion. Plos Med. 2008;5:e60.

2. Passi GR, Khan YZ, Chitnis DS. Chikungunya infection in neonates. Indian Pediatr. 2008;45:240-2.

3. Nair PM. Chikungunya in neonates. Indian Pediatr. 2008;45:60.

4. Chatterjee SN, Chakravarti SK, Mitra AC, Sarkar JK. Virological investigation of cases with neurological complications during the outbreak of haemmorhagic fever in Calcutta. J Indian Med Assoc. 1965;45:314-6.

5. Couderc T,Chritiun F, Schilte C, Disson O, Brigitte M, Guivel-Benhassine F et al. A mouse model for Chikungunya: young age and inefficient type-I interferon signaling are risk factors for severe disease. Plos Pathog. 2008;4:e29.

6. Chandak NH, Kashyap RS, Kabra D, Karandikar P, Saha SS, Morey SH, et al. Neurological complications of chikungunya virus infection. Neurol India. 2009;57:177-80.

7. Tournebize P, Charlin C, Lagrange M. Neurological manifestations in Chikungunya: about 23 cases collected in Reunion Island. Rev Neurol. 2009;165:48-51.

 

Copyright © 1999-2012  Indian Pediatrics