Chikungunya Virus Clinical Presentation

Updated: Feb 17, 2022
  • Author: Suganthini Krishnan Natesan, MD, FIDSA; Chief Editor: Michael Stuart Bronze, MD  more...
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Chikungunya fever is an acute febrile illness with an incubation period of 3 to  days. It affects all age groups and both sexes equally, with an attack rate (percentage of individuals who develop illness after infection) of 40-85%.

Patients present with abrupt onset of high-grade fever often reaching 102° to 105°F, with shaking chills that last 2 to 3 days. The fever may return for 1 to 2 days after an afebrile period of 4 to 10 days, hence called a “saddle-back fever.”

Prodromal symptoms are uncommon. However, sore throat, headache, abdominal pain, constipation, and retro-orbital pain have been reported during the acute phase of the illness.


Physical Examination

Clinical examination reveals high-grade fevers (up to 105°F), pharyngitis, conjunctival suffusion, conjunctivitis, and photophobia. Cervical or generalized lymphadenopathy has also been reported in rare cases. Other frequent manifestations include severe arthralgias, myalgias, and rash. [7, 10, 11]


The arthralgias usually are polyarticular and migratory, and frequently involve the small joints of the hands, wrists, and ankles, with lesser involvement of the large joints such as the knees or shoulders with associated arthritis. More than 10 joint groups may be involved simultaneously, incapacitating the patient. Swollen tender joints with tenosynovitis and crippling arthritis often are evident at the time of presentation. Joint pain is worse in the morning, gradually improving with slow exercise and movement but exacerbated by strenuous exercise.

Patients characteristically lie still in a flexed posture owing to the pain upon any movement. Rarely, sternoclavicular and temporomandibular joints are involved. Axial involvement is common, but hips are relatively spared. Inflammatory markers may be mildly elevated, but radiologic findings usually are normal. Joint edema is seen, but effusion is uncommon.

Although joint manifestations resolve completely within 1 to 2 weeks in most patients, about 10-12% develop chronic joint symptoms that may last for months. [75, 76, 78, 79] In 2017, Chang et al reported that, although about 25% of individuals with Chikungunya infection eventually develop persistent arthritis, follow-up testing revealed no detectable Chikungunya virus on synovial fluid analysis among 38 study participants. [80]

Cutaneous manifestations

Individuals with Chikungunya fever frequently present with a flushed appearance involving the face and trunk, followed by a diffuse erythematous maculopapular rash of the trunk and extremities, sometimes involving the palms and soles. The rash gradually fades; evolves into petechiae, urticaria, xerosis, or hypermelanosis; or resolves with desquamation. [81, 82]

A tourniquet test is positive in some patients, similar to dengue fever. In fact, some of the symptoms and signs of Chikungunya fever are almost indistinguishable from those of dengue fever. As both illnesses are transmitted by the same vector, coinfection has been reported in the literature. The differences between these diseases are discussed below (see Diagnostic Considerations).

Neurological manifestations

In the acute phase of the illness (reported during the outbreak in the Indian Ocean in 2005-2006), 23 patients presented with neurologic symptoms associated with abnormal CSF tests and positive CSF immunoglobulin M (IgM) or reverse-transcriptase polymerase chain reaction (RT-PCR) for Chikungunya virus. Clinical manifestations in this outbreak included altered mental status or behavior in 95%, headache in 30.4%, seizures in 26%, motor dysfunction in 4.3%, and sensorineural abnormalities in 8.7%. [83, 84, 85, 86, 87]


Rare presentations include severe rheumatoid arthritis, neuroretinitis, uveitis, hearing loss, myocarditis, and cardiomyopathy. [88, 89, 90, 91, 92, 93, 94, 95, 96, 97]


Diagnostic Criteria for Chikungunya Fever

The case definition of Chikungunya fever as proposed by the World Health Organization (WHO) Regional Office for Southeast Asia is discussed below. [98]

Suspected case

A suspected case involves a patient presenting with acute onset of fever, usually with chills/rigors, that lasts for 3 to 5 days, with pain in multiple joints/swelling of extremities that may continue for weeks to months.

Probable case

A probable case is characterized by conditions that support a suspected case (see above) along with 1 of the following conditions:

  • History of travel or residence in areas reporting outbreaks

  • Ability to exclude malaria, dengue, and any other known cause of fever with joint pains

Confirmed case

Chikungunya fever is confirmed if the patient meets 1 or more of the following findings irrespective of the clinical presentation (see also Workup):

  • Virus isolation in cell culture or animal inoculations from acute-phase sera 

  • Presence of viral ribonucleic acid (RNA) in acute-phase sera as determined with RT-PCR 

  • Presence of virus-specific IgM antibodies in single serum sample in acute phase or 4-fold increase in virus-specific IgG antibody titer in samples collected at least 3 weeks apart 



Chikungunya infection outbreaks result in large epidemics that can cause significant morbidity. Postinfection rheumatism with joint pain lasting months to years has been reported in the literature. Symptoms can range from transient arthritis with joint pains to severe joint destruction requiring antirheumatic therapy. It also has been shown to exacerbate pre-existing rheumatological conditions, resulting in impaired quality of life. Chronic pain and rheumatism have been demonstrated to affect the mental health of patients.

Although neurologic complications have been controversial, a range of neurologic manifestations were reported from La Reunion Island, with 24 patients diagnosed with Chikungunya-related encephalitis. Severe acute hepatitis, heart failure, respiratory insufficiency, cutaneous effects, and renal failure were identified during this outbreak.

Chikungunya infection in pregnant people has not been directly linked to congenital malformations. However, vertical transmission at the time of birth has been described in neonates, resulting in neurologic complications and cognitive developmental delays. [99, 100, 101]