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Congenital Chikungunya in Newborn along with Early Onset Sepsis: How To Interpret?

Vivek Chothe, Ramchandra Babar
Department of Paediatrics, MAM’s SSAM’s Sane Guruji Hospital, Hadapsar, Pune, Maharashtra, India

Address for Correspondence: Ramchandra Pandurang Babar, Department of Paediatrics, MAM’s SSAM’s Sane Guruji Hospital, Malwadi, Hadapsar, Pune 411028. Email: ramchandrababar@gmail.com

Keywords: Chikungunya virus, Congenital Chikungunya, Mosquito-borne disease, Neonatal sepsis, vertical chikungunya transmission, Neonate with chikungunya

Clinical Problem:
A male baby was born at 37 weeks 5 days of gestation via normal vaginal delivery, with the birth weight of 2.45 kg. Amniotic fluid was clear and the APGAR at 1, 5 and 10 minutes were 8, 10 respectively. The mother 27 years old 2^nd gravida, had an uneventful pregnancy and received regular prenatal care at attached hospital. Serological tests during first trimester for Hep B, HIV and syphilis were negative. Two days before delivery, mother experienced flu like symptoms and fever (38.5⁰c). Upon admission she was afebrile, with insignificant fever profiles. She was treated for unspecified sepsis during labour with antipyretics and antibiotics for 3 days. There was no history of PROM. The delivery was spontaneous and uneventful.
In the first two days of life, the infant was active, pink and accepted feed well. On the 4^th day of life, he began showing signs of decreased activity and refusal to feed, along with yellowish discolouration of sclera, suggestive of neonatal jaundice. He was transferred to the NICU for further management. Physical examination was largely unremarkable. Given the risk of perinatal infections, a sepsis workup was performed, revealing a total leucocyte count of 6790/L, a platelet count of 71000/L and a lymphocyte count of 53%. The Hb was normal (18.1/dL) with raised CRP level of 21.4 mg/L. Total Bilirubin was 15.28 mg/dL (direct 0.42 mg/dl). Blood culture and sensitivity tests were sent and IV antibiotics (Meropenem and Colistin) were initiated with double surface phototherapy.
On day 7 of life, the infant developed vesicular rashes, primarily on the back and limbs, along with intermittent fever (101⁰F). In view of these signs and symptoms antibodies test was done for dengue and chikungunya, which was insignificant. Vitals remained stable with no signs of neurological involvement. Blood tests showed further decreasing platelet count (41000/L). A heart ultrasound revealed a small Atrial septal defect with left- to- right shunt. Due to persistent fever along with thrombocytopenia repeat blood culture was sent and plan for FFP and RDP transfusion were made with intravenous immunoglobulin.
The baby later gone through multisystem involvement, had convulsion episodes. Appropriate anti-Seizure drugs were given to tackle the convulsions. MRI brain showed signs of encephalitis. After two sterile blood cultures, third was positive had growth of Enterococcus faecium; appropriate antibiotic therapy was given. Lumbar puncture showed no any growth hence plan of antibiotics continued till 14 days.
In between mother’s history was reviewed. She reported fever, rashes and persistent joint pain for three days after delivery. Hence, decided to rule out vertical transmission if any. Congenital chikungunya was confirmed on 30^th day of life through ELISA method. This problem indicates the perinatal infections of congenital chikungunya along with early onset sepsis.

Figure 1. Images of rashes on 7th day of life.