The Chikungunya epidemic currently attacked millions of people in Maharashtra, Karnataka, Tamilnadu, Andhrapradesh and Kerala. Chikungunya is not considered to be fatal. However, in 2005-2006, 200 deaths have been associated with chikungunya on Réunion Island and a widespread outbreak in Southern India (especially in Karnataka, Andhra Pradesh & Kerala). Chikungunya virus is highly infective and disabling but is not transmissible between people.( recent researches reported tramission from mother to foetus)

French researchers claims that viral strains isolated from the Reunion and the Seychelles clearly show a mutation from its East AND Central African origin, the reason for the widespread outbreak associated with it. There has been a specific amino acid mutation in EI gene of the virus making it more deadly.

Chikungunya (also known as Chicken Guinea) is a relatively rare form of viral fever resembling dengue fever; caused by an alphavirus that is spread by mosquito bites from the Aedes aegypti mosquito, though recent research by the Pasteur Institute in Paris claims the virus has suffered a mutation that enables it to be transmitted by Aedes Albopictus (Tiger mosquito). The name is derived from the Makonde word meaning "that which bends up" in reference to the stooped posture developed as a result of the arthritic symptoms of the disease.

Epidemiology
Chikungunya was first described in Tanzania, Africa in 1952 following an outbreak on the Makonde plateau. The disease was first described by Marion Robinson and W.H.R. Lumsden. An outbreak of chikungunya was discovered in Port Klang in Malaysia in 1999 affecting 27 people. In February 2005, an outbreak was recorded on the French island of Réunion in the Indian Ocean. In Mauritius, 3,500 islanders have been hit in 2005. There have also been cases in Madagascar, Mayotte and the Seychelles.

In 2006, there was a big outbreak in the Andhra Pradesh state in India. Nearly 200,000 people were affected by this disease. Some deaths have been reported but it was thought to be due mainly to the inappropriate use of antibiotics and anti inflammatory tablets. As this virus can cause thrombocytopenia, injudicious use of these drugs can cause erosions in the gastric epithelium leading to upper GI bleeding (due to thrombocytopenia). According to the National Institute of Virology, Pune out of362 samples from Kadappa district in Andhrapradesh state 139 were found positive for chikungunya.

Over 2000 cases of chikungunya fever were reported from Maharashtra state, in March 2006. In Orissa state 5000 cases of were reported in February 2006. In Bangalore, there was an outbreak of Chikungunya in May 2006. In Tamilnadu, 20,000 cases were reported in June 2006. Earlier it was found spreading mostly in outskirts of Bangalore, but now it has started spreading in the city also.Over 800000lakh cvases were reported from Karnataka state. Over 20000 cases were reported from Thiruvananthapuram, Aleppey, Kottayam, Ernakulam, Palakkad, Malappuram and Kozhikkode district in Kerala state. 10 deaths have been reported from Aleppy district. 800 cases were reported from Cherthala of Aleppy district.300 cases were reported from Kollam district.

National Institute of Virology in Pune says that the strain in India this tie is different from what was found during 1963(the first outbreak was recorded in 1963 in Calcutta) and 1974 epidemic and 98% similar to the one found in Reunion. The NIV says the new outbreak is from the African Genotype introduced to India 5yrs back.  More seropositivity is found among the age group between 51- 55 years.   

Chikungunya fever is caused by Chikugunya virus. They are spherical enveloped virions, 60 nm diameters and have single stranded positive sense RNA genome.

Characteristics of CHIKUNGUNYA virus
Virus classification
Group: Group IV ((+)ssRNA)
Family: Togaviridae
Genus: Alphavirus
Species: Chikungunya virus

Chikungunya virus is closely related to O'nyong'nyong virus. O'nyong'nyong virus caused a major epidemic of arthritis and rash involving at least 2 million people in Eastern and Central Africa in 1960s. After its mysterious emergence the virus virtually disappeared leaving only occasional evidence of its presence in Kenya.

The chikungunya virus is spread by mosquito bites from the Aedes aegypti mosquito. Mosquitoes become infected when they feed on a person infected with the chikungunya virus. Monkeys, and possibly other wild animals, may also serve as reservoirs of the virus. Infected mosquitoes can then spread the virus to other humans when they bite.

Aedes aegypti (the yellow fever mosquito), a household container breeder and aggressive daytime bitter which is attracted to humans, is the primary vector of chikungunya virus to humans. Aedes albopictus (the Asian tiger mosquito) may also play a role in human transmission is Asia, and various forest-dwelling mosquito species in Africa have been found to be infected with the virus.

Aedes breeds in artificial accumulations of water. It needs only 2ml of water for breeding. It lays eggs singly. They do not fly over long distance, usually less than 100 metres. Eggs can resist desiccation for upto 1year. The eggs will hatch when flooded by deoxygenated water.Aedes can spread the infection to next generation. 

Aedes is the first proved vector of a virus disease- Yellow fever. Human blood is preferred over other animals with ankles as a favourite bite area.

Symptoms
After an incubation period of 3-12 days there is a sudden onset of flu-like symptoms including a severe headache, chills, fever (>40°C, 104°F), joint pain, backache, nausea, vomiting, petechial or maculopapular rash usually involving the limbs and trunks. Migratory polyarthritis mainly affects the small joints of the hands, wrists, ankles and feet with lesser involvement of the larger joints. Joints of the extremities in particular become swollen and painful to the touch. Haemorrhage is rare. There can also be headache, conjunctival infection and slight photophobia.Redness of eyes may be the first symptom. There may be difficulty in looking upwards

In the present epidemic in the state of Andhra Pradesh in India, high fever and crippling joint pain is the prevalent complaint. Fever typically lasts for two days and abruptly comes down. The disease has a biphasic course also. Following 1-6 days of fever, the temperature returns to normal for 1-3 days and then there is a second period of fever for a few days. In the second phase of illness 80 % of people develop maculopapular rash on the trunk and extensor surfaces of the limbs. After 6 to 10 days patients recover completely. However joint pain, intense headache, insomnia and an extreme degree of prostration lasts for a variable period, usually for about 5 to 7 days. Rarely arthralgia and morning stiffness may persist for months.

However joint pain, intense headache, insomnia and an extreme degree of prostration lasts for a variable period, usually for about 5 to 7 days.

Dermatological manifestations observed in a recent outbreak of Chikungunya fever are as follows:

• Maculopapular rash like ulcers over scrotum, crural areas and axilla.
• Nasal blotchy erythema
• Freckle-like pigmentation over centro-facial area
• Flagellate pigmentation on face and extremities
• Lichenoid eruption and hyperpigmentation in photodistributed areas
• Multiple aphthous ulcers
• Lympoedema
• Multiple ecchymotic spots (Children)
• Vesiculobullous lesions (infants)
• Subungual haemorrhage.

Investigations
• A few patients develop Leucopenia.
• Elevated levels of aspartate aminotransferace (AST) and C-reactive protein
• Mildly decreased platelet counts.

Diagnosis
1.Isolation of the virus from blood. It is possible in the first 4-5 days of illness.  Sudden severe headache, chills, fever, joint and muscle pain are the commonest symptoms. The diagnostic tests include detection of antigens or antibodies in the blood, using ELISA (or EIA - enzyme immunoassay) or molecular techniques like polymerase chain reaction (PCR). The antibodies detected by serological assays like ELISA require an IgM capture assay to distinguish it from dengue fever

Differential Diagnosis
1. Dengue Fever
Of all the arthropod- borne viral diseases, Dengue fever is the most common. This infection may be asymptomatic or may lead to
1. Classical Dengue Fever
2 .Dengue Haemorrhagic fever without shock
3. Dengue Haemorrhagic fever with shock

The main vector is Aedes aegypti mosquito. The illness is characterised by a incubation period of 3 to 10 days. The onset is sudden with chills and high fever, intense headache, muscle and joint pains which prevent all movement. Within 24 hrs retro-orbital pain and photophobia develops. Other symptoms include extreme weakness, anorexia, constipation, colicky pain and abdominal tenderness. Fever is typically but not inevitably followed by a remission of a few hrs to2 days. The rash may be diffuse flushing, mottling, or fleeting pin point eruptions on face, neck and chest during the first half of the febrile period and a conspicuous rash that may be maculopapular or scarlatiform on 3rd or 4th day. Fever lasts for about 5 days.

Dengue haemorrhagic fever is confined exclusively to children less than 15 yrs of age. There may be plasma leakage and abnormal haemostasis, as manifested by a rising haematocrit value and moderate to marked thrombocytopenia.The fever may rise again producing a saddle-back fever curve. There may be generalised lymphadenopathy.

In dengue shock syndrome shock is present along with all the above criteria.

2. Yellow fever
It is a zoonotic disease affecting principally monkeys and other vertebrates. It shares clinical features of dengue fever but is characterised by more severe hepatic and renal involvement.. So death is more common in yellow fever than chikungunya.

3. Other viral fevers
Many of the viruses produce encephalitis, haemorrhagic fever or arthritis in various combinations. There may be high fever with backache and joint pain. Clinical features depend upon the type of virus causing infection.

a. SINDBIS virus infection: Transmitted among birds by mosquitoes. The disease begins with rash and arthralgia. Constitutional symptoms are not marked and fever is modest or lacking altogether.

b. MAYARO fever: Transmitted by Haemagogus mosquitoes. It causes a frequently endemic or epidemic infection of humans and appears to produce a syndrome resembling Chikungunya.

c. Epidemic Polyarthritis (ROSS RIVER virus infection): Constitutional symptoms are absent in many cases. Many patients are incapacitated by joint involvement.

d. Influenza: It is an acute respiratory illness caused by infection with influenza virus. Respiratory tract infection is accompanied by systemic signs and symptoms such as fever, headache and myalgia

4. Eruptive fevers like measles and German measles

5.West Nile Fever: West Nile Virus was recovered from the blood of a fever patient in Uganda in 1937. This virus is transmitted by Culex mosquitoes among wild birds. Humans are incidental hosts. Human infections are usually asymptomatic. Disease may present as a dengue like febrile illness with or without rash. Headache, myalgia, anorexia, nausea, epigastric pain, diarrhoea, lymphadenopathy may accompany the fever which lasts up to a week. The rash is maculopapular and non pruritic; unlike dengue. In its severe form it may cause aseptic meningitis or encephalitis especially in elder people and children. Rare complications include myocarditis, hepatits and pancreatitis.

6.Japanese Encephalitis: First occurred in Japan as asevere epidemic in 1924. Japanese Encephalitis virus has been isolated from the culex mosquitoes and mansonia. Onset is rapid. Encephalomyelitis developes within 2-4 days. There may be fever, headache, altered sensorium, coma, convulsions, neck rigidity, C S F pleocytosis etc

Complications
• Super added infection with bacteria
• Meningo encephalitis
• Death occurs in immunocomprised patients.
• Myocarditis
• Pneumonias
Complications were observed due to injudicious application of certain anti-inflammatory drugs (as reported by www.chikungunya.co.uk)

Prevention
The best way to avoid CHIKV infection is to prevent mosquito bites.

There is no vaccine or preventive drug except homoeopathic medicines.. Preventive tips are similar to those for dengue or West Nile virus:

• Use insect repellent.
• Wear long sleeves and pants.
• Have secure screens on windows and doors to keep mosquitoes out.
• Get rid of mosquito breeding sites by emptying standing water from flower pots, buckets and barrels. Change the water in pet dishes. Drill holes in tire swings so water drains out. Keep children's wading pools empty and on their sides when they aren't being used.
• Additionally, a person with chikungunya fever or dengue should limit their exposure to mosquito bites in order to avoid further spreading the infection. The person should stay indoors or under a mosquito net.       Mix coconut oil and neem oil and external application of it will prevent mosquito bite.

Immunity
One attack confers life long immunity.

Homoeopathic Prophylaxis
As per the guidelines laid down by Dr. Samuel Hahnemann in the Organon a Genus epidemics has to be found out in the specific area and it could be the best to be found out in the specific area and it could be the best prophylactic remedy.

Many homeopaths consider Eupatorium perfoliatum as a preventive medicine for Chikungunya. The most commonly suggested potency as prophylaxis is 200C of Eupatorium perfoliatum. As per the reports the homoeopathic remedies useful for propylaxis are - Eupatorium Perfoliatum, Gelsemium, Rhustox, Bryonia Alba, Ars alb ,Aconite and Polyporus.

The Karnataka Board of Homoeopathic System of medicine announced Rhustox 200 & Pyrogen 200 as the Genus Epidemicus for Chikungunya cases. In Tamil Nadu Homoeopathic physicians distributed Rhustox and Eupatorium for more than 4000 persons as a preventive prescription.in Andhrapradesh Government distributed medicine to 2 Lakh people.

Treatment
Chikungunya fever is usually self-limiting and will resolve with time. Symptomatic treatment is recommended after excluding other more dangerous diseases. There is no vaccine currently available for Chikungunya. Supportive care with rest is indicated during the acute joint symptoms. Movement and mild exercise tend to improve stiffness and morning arthralgia, but heavy exercise may exacerbate rheumatic symptoms.

Homoeopathic Treatment
Aphorism 100-102 is dealing with the treatment of epidemic diseases. According to Dr.Hahnemann, a carefully observing physician can arrive so nearly at knowledge of the true state of the epidemic from the examination of even the first and second patients and can even find a suitable homoeopathic remedy for it. Dr. Hahnemann recommends investigating each epidemic disease as a new and unknown case and selecting medicine according to its symptom similarity.

Homoeopathy has a very good scope in the treatment of chikungunya. Initially indicated acute remedies may give relief which may be followed by constitutional remedy in order to get rid of post fever arthralgia

Homeopathy offers many medicines which may help in Chikungunya. These include medicines like Eupatorium-perf, Pyroginum, Rhus-tox, Cedron, Influenzinum, China, Arnica, Belladona, Bryonia, Nux vomica, Sulphur etc. Eupatorium Perfoliatum Q (tincture, 3 to 5 drop dose) will remove the debilitating joint pains and cut short the intensity and duration of the disease. Other potencies may be used according to the intensity of the case. In Andhrapradesh medicines such as Eupatorium200 & Belladonna has cured number of cases.

Important rubrics that can be selected based on symptom totality (Synthesis Repertory)

1. FEVER CHILLINESS with
2. FEVER ERUPTIVE fevers
3. EXTREMITIES PAIN fever during
4. EXTREMITIIES PAIN joints
5. GENERALS SWELLING joints of
6. BACK PAIN fever during
7. HEAD PAIN heat during
8. STOMACH NAUSEA fever
9. STOMACH VOMITING heat during
10. GENERALS WEAKNESS fever during

Medicines:
Nux vomica - 19/8
Natrum mur - 17/9
Bryonia - 16/7
Eup. Per - 15/6
Pulsatilla - 14/7
Rhustox - 11/5

Predominant Miasm: Psora

Indications of some important Homoeopathic remedies:

1. Eupatorium perfoliatium: - Pain in the limbs and muscles with fever. There may be severe bone pain. Swelling of ankles and feet. Aching pain in bones of extremities with soreness of flesh.great thirst, perspiration relieves all symptoms except head ache.200 potency is found to be more effective. This medicine is highly effective in post fever arthralgia (Mother tincture 5 drops tds for 3-5 days)

2. Gelsemium: - associated with severe headache and coryza. Thirstlessness, slow pulse, muscular pains. There may be drowsiness, dullness and dizziness. < In damp weather.

3. Rhustox: - Fever with polyarthritis and maculopapular rashes. Pain and stiffness in joints. < first motion. Rheumatism in cold seasons. Restlessness. < Cold. Wet, Rainy weather.200 potency is most effective

4. Bryonia: - Fever with aching in every muscle. Dry mouth with excessive thirst, knees stiff and painful. Joints red, swollen, and hot with stitching and tearing pain. < by motion; better rest. Bursting, splitting headache as if everything would be pressed out.

5. Ars Alb: - Restlessness and anxiety during fever, severe weakness. Unquenchable thirst, nausea and vomiting. Fever< mid day or midnight.

6. Pulsatilla:- Fever with chilliness,thirstlessness and wandering joint pains

7. China: - Pain in the limbs and joints as if sprained. < slight touch.
                > Hard pressure. Swollen joints. Debilitating night sweats.

8. Belladona: High fever with burning heat. No thirst with fever. Joints swollen, red, shining with red streaks radiating. Heat, redness, throbbing and burning.

9. Pyrogen: Septic fevers, temperature rises rapidly. Great heat with profuse hot sweat. But sweating does not cause a fall in temperature, aching in limb and bones.

10. Nux vomica: fever with chilliness, nausea vomiting, ineffectual urging for stool.

11. Sulphur: used as an intercurrent.

Recently a homoeopathic doctor claims that he will cure chikungunya with a single dose of  Polyporus Pinicoloa 1000x

REFERENCES:
1. Harrison’s Principles of Internal Medicine.
2. Homoeo Times – International Journal on clinical evidence
3. Vital Informer – Monthly Medical News Letter
4. Homoeopathic Materia Medica and Repertory by W.Boericke.

Internet:
1. www.wikipedia.org/wiki/Chikungunya
2. www.cbwinfo.com/Biological/Pathogens/CHIK.html
3. www.phacaspc.gc.ca/msdsftss/msds172e.html
4. www.hpathy.com
5. www.chikungunya.co.uk

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