Tenosynovitis and Vascular Disorders Associated with Chikungunya Virus-Related Rheumatism

Tothe Editor—We read, with great interest, the study by Borgherini et al. [1], who recently reported 157 cases of Chikungunya virus (CHIKV) infection that were diagnosed on Reunion Island during the 2005–2006 epidemic on islands in the Indian Ocean. Because an increasing number of cases have been diagnosed in returned travelers [2, 3], we would like to highlight some clinical signs that may help doctors to recognize the disease and distinguish it from other diseases, such as dengue, whose distribution can overlap with that of CHIKV infection. As early as 1955, Robinson [4] proposed clinical signs that would improve the differential diagnosis in outbreaks of other febrile illnesses involving arthralgias and that were more characteristic of CHIKV infection, particularly the lack of pain when moving the eyes and the extended duration of joint pain. Since 2005, we have examined and observed 80 patients in Marseille, France, who have had imported CHIKV infection; some of these patients have been described elsewhere [2, 5]. Within 10 days after disease onset, most patients presented with an acute stage of febrile polyarthritis and evanescent rash, as described by Borgherini et al. [1]. However, after the acute phase, the infection often progressed to a second phase <10 days after the onset of disease. In fact, many patients received consultations at that time, because they remained symptomatic, with peripheral rheumatism. Following transient improvement, many infected travelers presented with at least 1 of the following rheumatic manifestations: (1) edematous polyarthritis in the fingers and toes, with morning pain and stiffness; (2) severe tenosynovitis of the wrists, hands, and ankles; and (3) exacerbation of pain in previously injured joints. This CHIKV-related rheumatism was common in elderly patients, lasted for months, and was responsible for dramatic impairment in daily activities. In addition, during the initial few weeks, tenosynovitis was much more common, painful, and disabling than arthritis. Moreover, an intense pain when pressure was placed on the anterior wrist (the most frequent location) or the forefoot seemed to be characteristic of the disease. We also observed carpal or cubital tunnel syndromes as consequences of multiple hypertrophic tenosynovitis of the anterior wrist. We observed other joint manifestations that were not reported by Borgherini et al. [1], such as large joint effusions, hygromas, bursitis, and axial pain, especially in areas where arthritis or trauma previously occurred. Finally, we have seen 9 patients who developed de novo bilateral vascular disorders (mostly Raynaud phenomenon) that lasted for several weeks during the second and third months after disease onset and that were not associated with wrist tenosynovitis [5]. The association of recent rheumatism involving joints and tendons and de novo Raynaud phenomenon is unexpected in the context of an arboviral disease and may lead to CHIKV infection being misdiagnosed as rheumatoid arthritis or another rheumatologic disease. CHIKV infection appears to be an emerging arboviral disease that all physicians should be prepared to encounter among travelers and migrants. The additional characteristics reported here—in particular, the “2-phased” disease evolution, the presence of multiple tenosynovitis typically demonstrated with pressure on the wrists, and the onset of vascular disorders, such as Raynaud phenomenon, during the second and third months—may also be helpful in diagnosis. Potential conflicts of interest. All authors: no conflicts.