Can Chikungunya be fatal? What published literature has to say

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• “Torres et al describe four Venezuelan patients with a severe and/or lethal course who exhibit unusual manifestations of the disease. Case 1 describes a 75 year-old man with rapid onset of septic shock and multi-organ failure. Cases 2 and 3 describe two patients with rapid aggressive clinical course who developed shock, severe purpuric lesions and a distinct area large of necrosis in the nasal region. Case 4 depicts a splenectomized woman with shock, generalized purpuric lesions, bullous dermatosis and acronecrosis of an upper limb. Chikungunya fever in the Western hemisphere may also associate with atypical and severe manifestations. Some patients experience a life-threatening, aggressive clinical course, with rapid deterioration and death due to multisystem failure.” Torres JR, Leopoldo Códova G, Castro JS, et al. Chikungunya fever: Atypical and lethal cases in the Western hemisphere: A Venezuelan experience. IDCases. 2014 Dec 18;2(1):6-10.

• “Chikungunya virus is a mosquito-borne alphavirus which causes fever, rash, and arthralgia. In the past, life-threatening complications were very rarely reported. However, during the recent worldwide outbreaks, there have been several reports of unusually severe complications and deaths. Malaysia is experiencing a nationwide outbreak of CHIKV, with over 10 000 patients affected since April 2008. Sam et al report the first case of culture-confirmed CHIKV-associated death in Malaysia, in a patient with fever, rash, acute exacerbation of pre-existing heart failure, rhabdomyolysis, and multiple organ failure. CHIKV infections may cause atypical, severe or fatal presentations.” Sam IC, Kamarulzaman A, Ong GS, et al. Chikungunya virus-associated death in Malaysia. Trop Biomed. 2010 Aug;27(2):343-7.

• “Background: In addition to classical manifestations of Chikungunya infection, severe infections requiring hospitalization were reported during outbreaks in India in 2006. Objectives: To describe the systemic syndromes and risk groups of severe Chikungunya infections. Study design: We prospectively investigated suspected Chikungunya cases hospitalized in Ahmedabad, Gujarat during September-October 2006, and retrospectively investigated laboratory-confirmed Chikungunya cases hospitalized with neurologic syndromes in Pune, Maharashtra. Hospital records were reviewed for demographic, comorbidity, clinical and laboratory information. Sera and/or cerebrospinal fluid were screened by one or more methods, including virus-specific IgM antibodies, viral RNA and virus isolation. Results: Among 90 laboratory-confirmed Chikungunya cases hospitalized in Ahmedabad, classical Chikungunya was noted in 25 cases and severe Chikungunya was noted in 65 cases, including non-neurologic (25) and neurologic (40) manifestations. Non-neurologic systemic syndromes in the 65 severe Chikungunya cases included renal (45), hepatic (23), respiratory (21), cardiac (10), and hematologic manifestations (8). Males (50) and those aged ≥60 years (50) were commonly affected with severe Chikungunya, and age ≥60 years represented a significant risk. Comorbidities were seen in 21 cases with multiple comorbidities in 7 cases. Among 18 deaths, 14 were males, 15 were aged ≥60 years and 5 had comorbidities. In Pune, 59 laboratory-confirmed Chikungunya cases with neurologic syndromes were investigated. Neurologic syndromes in 99 cases from Ahmedabad and Pune included encephalitis (57), encephalopathy (42), and myelopathy (14) or myeloneuropathy (12). Conclusions: Chikungunya infection can cause systemic complications and probably deaths, especially in elderly adults.” Tandale BV, Sathe PS, Arankalle VA, et al. Systemic involvements and fatalities during Chikungunya epidemic in India, 2006. J Clin Virol. 2009 Oct;46(2):145-9.

• “Chikungunya fever is a viral infection transmitted to humans by the bite of infected mosquitoes. Typical chikungunya virus (CHIKV) infection results in an acute febrile illness characterized by severe joint pain and rash. Although chikungunya is generally not considered life threatening, atypical clinical manifestations resulting in significant morbidity have been documented, especially during epidemics. This review describes atypical manifestations following CHIKV infection reported in the literature, categorized as neurological, cardiovascular, skin, ocular, renal and other manifestations. The importance of vertical transmission from an infected mother resulting in neonatal infection is also highlighted. CHIKV infection can result in severe illness needing intensive care, with significant mortality. While there are many deaths reported which are directly attributable to CHIKV infection, background mortality is also increased during epidemics. In this context, considering CHIKV infection a benign and non fatal illness has to be revisited.” Rajapakse S, Rodrigo C, Rajapakse A. Atypical manifestations of chikungunya infection. Trans R Soc Trop Med Hyg. 2010 Feb;104(2):89-96.

• “Mavalankar et al report an increase in mortality rates in Ahmedabad during August–November 2006 (when a chikungunya epidemic occurred in this city) compared with previous months in 2006 and the same months in the past 4 years. The highest number of chikungunya cases was also reported in August and September. The city had ≈2,944 additional deaths during August–November 2006. Epidemiologic evidence shows that the increase in deaths in Ahmedabad was largely attributable to the chikungunya epidemic. Given poor reporting of deaths, an unexplained cause of death cannot be ruled out. Mortality rate data for Ahmedabad are consistent with observations of other researchers that the virus may have mutated and become more dangerous than reported. Public health authorities must investigate recent epidemics. Otherwise, developing countries may not be able to detect and combat severe future epidemics of other reemerging diseases such as avian influenza and severe acute respiratory syndrome.” Mavalankar D, Shastri P, Bandyopadhyay T, et al. Increased mortality rate associated with chikungunya epidemic, Ahmedabad, India. Emerg Infect Dis. 2008 Mar;14(3):412-5.

• “Serious complications are not common, but in older people, the disease can contribute to the cause of death.” WHO Chikungunya Fact sheet Updated April 2016

IMA – Excerpts from President Secretaries Meeting: Maintain Professional Dignity & Honour MCI Ethics Regulations

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• A physician shall uphold the dignity and honour of his profession.
• 1.2 Maintaining good medical practice: 1.2.1 The Principal objective of the medical profession is to render service to humanity with full respect for the dignity of profession and man. Physicians should merit the confidence of patients entrusted to their care, rendering to each a full measure of service and devotion. Physicians should try continuously to improve medical knowledge and skills and should make available to their patients and colleagues the benefits of their professional attainments. The physician should practice methods of healing founded on scientific basis and should not associate professionally with anyone who violates this principle. The honoured ideals of the medical profession imply that the responsibilities of the physician extend not only to individuals but also to society.
• Appendix 1: Declaration: At the time of registration, each applicant shall be given a copy of the following declaration by the Registrar concerned and the applicant shall read and agree to abide by the same:

a. I solemnly pledge myself to consecrate my life to service of humanity.
b. Even under threat, I will not use my medical knowledge contrary to the laws of Humanity.
c. I will maintain the utmost respect for human life from the time of conception.
d. I will not permit considerations of religion, nationality, race, party politics or social standing to intervene between my duty and my patient.
e. I will practice my profession with conscience and dignity.
f. The health of my patient will be my first consideration.
g. I will respect the secrets which are confined in me.
h. I will give to my teachers the respect and gratitude which is their due.
i. I will maintain by all means in my power, the honour and noble traditions of medical profession.
j. I will treat my colleagues with all respect and dignity.
k. I shall abide by the code of medical ethics as enunciated in the Indian Medical Council (Professional Conduct, Etiquette and Ethics) Regulations 2002.
• 1.7 Exposure of Unethical Conduct: A Physician should expose, without fear or favour, incompetent or corrupt, dishonest or unethical conduct on the part of members of the profession.

IMA Views

• It has to be a proven misconduct.
• The onus to prove will lie with the complainant.
• The complaint has to be filed with the Medical Council of India (MCI) or the state medical council and not in the media or social media.

Section 499 in The Indian Penal Code: Defamation.—Whoever, by words either spoken or intended to be read, or by signs or by visible representations, makes or publishes any imputation concerning any person intending to harm, or knowing or having reason to believe that such imputation will harm, the reputation of such person, is said, except in the cases hereinafter expected, to defame that person.

Section 500 in The Indian Penal Code: Punishment for defamation.—Whoever defames another shall be punished with simple imprisonment for a term which may extend to two years, or with fine, or with both.
(Contributions from Dr RN Tandon)

Fruits and vegetables improve BP control in CKD patients with associated metabolic acidosis

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Treating metabolic acidosis in chronic kidney disease (CKD) patients with base-producing fruits and vegetables but not sodium bicarbonate lowered the systolic blood pressure followed by use of fewer anti-hypertensive drugs and those too in lower doses, says a study presented at the Hypertension 2016 Scientific Sessions of the American Heart Association (AHA) in Orlando, Florida on September 14, 2016. The treatment costs were also reduced.

In the study, researchers randomized 108 subjects with CKD stage 3 eGFR (30-59 ml/min) and metabolic acidosis into three groups: One group received fruits and vegetables to reduce dietary potential renal acid load (PRAL) 50%, the second group was given oral sodium bicarbonate to reduce PRAL 50% and the third group received usual care and no alkali.

After five years, the average systolic blood pressure was lower in the fruit and vegetable group (125 mm Hg) vs sodium bicarbonate (135 mm Hg) group vs no alkali group (134 mm Hg). Also, the average cost of drugs to maintain the blood pressure was nearly half in the fruit and vegetable group ($79,760) vs the sodium bicarbonate group ($155,372) vs no alkali group ($152,305) at five years.

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