Case Study: Chikungunya and Lupus, an Ill-Fated Diagnosis

Nov 28, 2016

Diagnosed with systemic lupus erythematosus and chikungunya, a woman embarks on a cross-continent trip for treatment and diagnosis at a city hospital.

It's 4:45 p.m. and I'm wrapping up with my last patient of the day. There’s a commotion at the nursing station about a late appointment. “Would the doctor still see my daughter?” a woman asked.

This is a new patient:  a 30-year-old female accompanied by her mother and a 5-year-old girl. They’re apologetic and explain they just arrived from John F. Kennedy International Airport from the Caribbean.

The daughter says she's been having worsening shortness of breath with skin photo sensitivity and joint pains. She’s been treated by to two physicians in her hometown, had labs drawn and was given oral tablets (unable to recall name). The labs show that she has positive serologies for systemic lupus erythematosus and chikungunya. I review the previous diagnoses with the daughter and her mother, but they stare at each other in disbelief and surprise. The daughter is escorted to the emergency department for treatment of dyspnea. She has been struggling to breathe and has been in pain for several weeks without proper medical care.

Chikungunya is a single-stranded RNA virus spread by tropical mosquito vectors. The incubation period lasts several days, with abrupt clinical onset between day seven and 10. Anti-CHIKV IgM antibodies can be detected in patients from 4-6 days and remain detectable for weeks to months. Patients may present with fevers, joint pain, muscle pain, rash and conjunctivitis with laboratory abnormalities including leukopenia, thrombocytopenia and elevated inflammatory markers. Chikungunya is an African word meaning “to walk bent over,” which is a fitting description as it can lead to a great degree of joint pain. Though this particular patient did have a positive indirect measles immunoglobulin M (IgM) serology test, the labs were drawn two months ago making an acute infection far less likely. 

The patient stated that she had a first degree relative with systemic lupus erythematosus (SLE), which is common in the African American and Afro Caribbean population. During her hospitalization, she had an extensive workup revealing serositis with low compliments and high titers of double-stranded DNA confirming our suspicions of an active lupus flare. She did well with a course of steroids and discharged with hydroxychloroquine. The patient has a follow up clinic appointment to monitor her progress and manage her care.

Rheumatologic diseases are distinct and just one disease can manifest itself with a multitude of diagnosable health problems requiring tailored therapy – which can cost patients thousands of dollars each month. Regrettably, many patients cannot afford the price of healthcare and suffer in silence while their disease progresses.

We see many of these patients at our hospital which is not a luxurious hospital with peaceful waterfalls and Rodin statues. Inner city hospitals like ours are well-oiled machines with churning wheels. Our mission is to provide superior care for patients who come from near and abroad.

 

Irina Litvin, D.O., is a physician and rheumatology fellow at SUNY Downstate in Brooklyn, N.Y.

 

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