Microsoft word - treatment protocol on chikungunya.doc

Management Protocol for suspected cases of
Chikungunya
Prepared jointly by IMA Kerala State & Government epidemic Cell
I. Medical Management
First contact with the doctor
• Fever screened by the doctor with arthralgia/arthritis/rashes Case definition
• Suspected case - sudden onset with fever and arthralgia • Confirmed case - same as suspected with IgM ELISA +ve.(in case of outbreaks 5 - 10% of cases need be confirmed by the laboratory) Classification of cases
Need for referral
• Oliguria / Anuria / jaundice / any other organ dysfunction • Fever persisting for more than 7 days o first and second trimester pregnancies Acute cases
• Paracetamol - 2 to 3 g/24 hours x 3 days + adequate • Paracetamol injection preferably to be avoided • Movement and mild exercise during pain free period to • Avoid heavy exercise
• Avoid Aspirin
• Routine use of Steroids may be avoided
Note: though a potent anti-inflammatory drug steroid, can not be given for mass treatment because of major side effects and chance of misuse Fever persisting with arthralgia /
arthritis
• Other NSAIDS indicated in cases where there is pain not • NSAIDS to be selected judiciously depending on patients tolerance, availability and cost factors. Drugs used
• Diclofenac 50 mg tid • Aceclofenac Duration of treatment depends upon
the clinical response
• Fever subsides • During the course of treatment, evaluate the patient clinically • Tramadol 50 - 100mg 4 - 6 hourly maximum 400mg /day. -------------------------------------------------------------------------- • Hydroxy Chloroquin 200mg once daily is preferred in prolonged arthralgia / arthritis cases (theoretically it has less chance of retinal damage when compared to Chloroquin). • Gastro protective agents to be used with NSAIDS. H2 blockers / proton pump inhibitors
• Pantoprazole • Omeprazole • Rabiprazole In pregnancy
• Commonly used drugs are; • Paracetamol • Mefenamic acid First Trimester
• Risk of miscarriage, but no malformations documented Third Trimester
• Fetal distress and pre-mature labour • NSAIDS may be avoided Atypical presentations
• Fever with thrombocytopenia - not very severe as in dengue 2. Dermatological Manifestations and Management in Chikungunya

Dermatitis involving seborrhoeic areas
• Central part of face with hyper pigmentation of the body
• ‘V’ areas of Body • Axilla and Groin Pruritus
Erythematous Rashes of Body/Limbs
Scrotal Dermatitis / Scrotal ulcers
Lichenified tender lesions involving
legs
Central part of face with hyper
pigmentation
Pruritis
Erythematous rashes of body / limbs
• If symptomatic Lotiocalamine locally and Oral Antihistamines Scrotal ulcers
• Cleansing measures • Saline compress • Topical antibiotics • Systemic antibiotics, if necessary esp. Broad Spectrum Antibiotics. 3. Musculoskeletal manifestations and Management
- Ankle and Foot, Knee, Spine, Wrist, Shoulder, Phalanges, - Tendo Achilles, Hamstrings, Evertors of foot, Extensor Pollicis Brevis & Abductor Pollicis Longus, Rotator Cuff. • Bathing, Grooming & Dressing were the most common • Washing clothes & Grinding masala were the most common Instrumental Activities Daily Living (IADL) affected • Average workday lost--- 45 days, range from 2 wks – 60 Proposed functional classification (after one month of following fever)
Grade II
Grade III
Management Strategies
Grade II
Grade III
Oral steroids-short course tapering Rest in sub acute period & Exercise in Pulsed Ultra Sound Therapy (UST) if Local steroid infiltration in tendon sheath Monitoring of follow up of Functional
• Joint Count – Total number of inflamed joints & Musculoskeletal sequalae
• Enthesis Count – Total No: of inflamed / tender tendons • Application of Functional Grading & Return to activity • Can squat/climb step/walk without difficulty/ needs Exercises
• Must be non-weight bearing, low repetition, slow and taken through the full range, either done actively or active assisted as tolerated? Eg:- 1. Slowly trying to touch the occiput (back of head) with the palm of your hand in the lying down position. Slowly bending the knee towards the chest as tolerated. Slow and ankle exercise (move up and down and clock wise) Slowly trying to touch the low back with the dorsum of the hand Pulley assisted exercises if shoulder and rotator cuff is involved only slow flexion exercises advised. Cold Compresses
• Cloth soaked in ice cold water is applied or small ice cubes rubbed over the inflamed tendons and joints for five minutes twice daily. Contra- indications
• All standard contra indications for exercises like –heart • All standard contra indications for steroids apply – like uncontrolled diabetes reduced immunity and TB • All standard contra indications for ice and apply eg: • Short course steroids are used with caution only for musculo skeletal sequalae after the acute phase is over, that is more than 2 weeks since the fever has come down. 4. Neuro psychiatric problems- management guidelines

1. Functional overlay
• Persistent, severe & distressing pain not fully explained by Persistent Somatoform Pain Disorder-
Management guidelines
• Therapeutic dialogue (Communication-verbal & non-verbal listening and touch, Address FEAR, emotional conflicts, psychosocial problems) Encourage gradual re-entry into routine work 2. Adjustment disorder
• Subjective distress & emotional disturbance interfering with social functioning, arising in a period of adaptation to a ‘serious’ ‘physical illness -media-scare • Communicate essential information (stress can produce • Emotional support, encourage return to routine 3. Depression
• Sadness of mood, lack of interest, easy fatigability, insomnia, loss of appetite, hopelessness, worthlessness, suicidal ideas…lasting for more than two weeks • Responds well to antidepressants 4. Insomnia
• Management of pain and reassurance alone needed in most 5. Delirium
• Acute onset of confusion, clouded thinking or disorientation • If not responding, REFER to physician or neurologist

Source: http://imabehala.org/yahoo_site_admin/assets/docs/TPOCG.218122521.pdf