CENTRO‐FACIAL PIGMENTATION IN ASYMPTOMATIC CONGENITAL CHIKUNGUNYA VIRAL INFECTION (2012)

22 June 2011 Dear Editor, Chickungunya fever is caused by an alphavirus (CHIKV) transmitted by Aedes mosquito. It is a flue-like self limiting illness characterized by high fever and severe arthralgia, which may be accompanied by muco-cutaneous manifestations.1 We report a case of 20-day-old female infant with asymptomatic chikungunya infection who presented with brownish black pigmented macular lesions over central areas of face involving nose, paranasal and perioral areas (Fig. 1). The baby was otherwise healthy and all other clinical parameters were normal. All routine investigations, including complete blood count , liver function tests, renal function test, urine microscopy and a chest X-ray of the baby were within normal limits. History revealed that the baby's mother had a sudden onset of high-grade (F−103°F) continuous fever, incapacitating joint and muscle pain of both limbs at 36 weeks of pregnancy 5 days before delivery. She developed generalized, blenchable, itchy erythematous macula-papular rash all over her body on second day of the fever. She consulted a physician who suspected chikungunya fever because of the endemicity of chikungunya in this region. The diagnosis was confirmed by IgM µ capture ELISA test (National institute of Virology, Pune, India). She was treated with injection diclofenac sodium for 3 days and tablet antihistaminics for 7 days. Fever subsided within 3 days and joint pains gradually decreased but persisted at the time of reporting the present case. Skin rashes gradually decreased and disappeared in 7 days. Five days after development from the fever, she delivered a normal healthy female child. At 10 days after birth, the child developed brownish black pigmented macules around its mouth and nose, which gradually increased to its present size. The baby did not suffer from fever or any other systemic illness but tested positive for chickungunya by IgM µ capture ELISA test. The baby's macular centro-facial pigmentation did not disappear up to 3 months of follow up. The mother did not have pigmentation anywhere on her body. Both mother and child tested negative for Venereal Disease Research Laboratory, HIV, dengue fever TORCH (T for Toxoplasmosis, O for other infections like syphilis, hepatitis B, Coxsackie, Epstein barr virus, vericella zoster virus, human parvovirus, R for Rubella, C for Cytomegalovirus and H for the Herpes simplex virus) and ASLO tests for Sterptococal throat infection and RA test for rheumatoid arthritis to exclude other causes of joint pains, fever and pigmentation. A 20-day-old female child of chikungunya infected mother showing centro-facial pigmentation ‘chik sign’. Vertical transmission of chikungunya virus from mother to child has been demonstrated.2 Such congenital infections lead to cardiac, haematological, and neurological dysfunctions rather than arthralgia, and are fatal if no treated. Cutaneous manifestations of chikungunya such as erythema, pigmentation, vesiculo-bullous eruptions and desquamating skin lesions have also been described in patients with chickungunya.3 Recently, Riyaz et al. have described a striking nose pigmentation named as ‘chik sign’ in patients who had chickungunya fever in the past, although the precise mechanism of nose pigmentation remains unclear.4 Our case was unusual as the infant tested seropositive for chikungunya but displayed no other signs or symptoms of infection except centro-facial hyperpigmentation. Congenital chikungunya should be considered as one of the differential diagnosis in infants presenting with asymptomatic centro-facial hyperpigmentation.