After a vacation, knee pain and a rash

The man felt foolish sitting in the waiting room of the Travel Medicine clinic. He didn't understand why his wife had insisted that he go see the doctor. After all, he was starting to feel better, and didn't she realize that he was already overworked at the office, trying to sift through the jumble of unattended cases that had piled up during their two-week jaunt to the Caribbean?

He already felt as if it had been months since he had swum in the Atlantic Ocean, tried parasailing, and hiked around beautiful hills and waterfalls.

Although he had been back home for a week, he still had lingering pain in both knees, which he attributed to being very physically active on vacation.

Of course, his wife was worried about the constellation of symptoms that had developed about two days after his return. He had complained of headaches, sore throat, and extreme fatigue. The following day, he was having high fevers and noted an impressive rash on his chest and back.

He felt aches all over his body, but in particular, his knees and ankles. Both knees had also swollen, which was unusual for him.

Now, four days later, the fevers were gone along with the headaches. Even the rash on his body was disappearing, with only a faint redness remaining. The joint pains and fatigue persisted, though, and were aggravated by even the simplest of activities, such as walking. His wife, who had accompanied him on the trip, was fine.

Back in the examination room, the man started to tell his story, only to be interrupted by his wife who described his symptoms in much greater detail than he felt was necessary.

The physician listened patiently, and asked a few questions: Had he experienced any easy bruising or bleeding? Did he have any nausea or vomiting? Did anyone else have similar symptoms? All no.

The primary care doctor had been most concerned about malaria, because his patient had only sporadically taken pills to prevent it on his trip.

But that doctor did not do any work-up and had sent him to the travel clinic for tests.

When the physician was done examining him, the man asked, "So, doc, it sounds like the flu, right? I mean, it is November, after all."

After a pause, the physician responded, "Well, it could have been the flu, but I am more suspicious of some other diagnoses, especially given your recent travel.

"I'm glad to hear that you are getting better. If this is what I suspect it is, the joint pains may linger for several more weeks, possibly months. I would encourage you to take it easy and slowly build up your activity level, as you can tolerate.

"Acetaminophen or NSAIDs like ibuprofen may help with the pain. Otherwise, there isn't much that I can offer, although I do expect you to recover."

The physician suspected - but did not yet know - that the patient had contracted Chikungunya on his Caribbean vacation.

It is caused by a virus spread from mosquito bites, and the most common symptoms are fever and joint pains, and often including headaches, muscle pains, rash and joint swelling.

The typical incubation period for this virus is three to seven days after the mosquito bite, although it can be up to 12 days. As in this case, most people start to recover within a week although the joint pains and swelling can last much longer, upwards of months or years. It is rarely fatal.

Although the physician was confident about the Chikungunya diagnosis, she still needed to rule out other diseases, such as Dengue, malaria, and leptospirosis.

Routine labs showed a low number of white blood cells to help fight off infection, and of platelets, which help with clotting. Electrolytes and kidney function were normal, but there was a mild elevation in the liver function tests. These labs were consistent with Chikungunya.

Also, blood smears were negative for malaria, and respiratory viral panel testing ruled out influenza or other respiratory viruses.

Serum antibody testing for Chikungunya was sent to the state public health laboratory, and this returned positive, which confirmed the diagnosis. Antibodies typically develop one to two weeks into the illness, but sometimes early testing can be falsely negative. In those cases, repeat antibody testing is done in four to six weeks to see whether antibodies are present.

Long considered a disease endemic to parts of Africa, South and Southeast Asia, Chikungunya has been documented in several Caribbean countries as of October 2013 and more recently in southern parts of the U.S.

The virus is transmitted by the same bug that carries the Dengue virus, the Aedes mosquito. Dengue and Chikungunya viruses circulate in the same areas, and their symptoms overlap.

Indeed, patients can be infected with both viruses at the same time. Given the cases in the U.S. and other parts of the Western hemisphere, Chikungunya needs to more on the minds of all health care providers, not just those in Travel Medicine.

While there is no vaccine or drug to prevent or treat Chikungunya, people are advised to take steps to prevent mosquito bites, especially if traveling to highly endemic areas.

These include wearing long-sleeved shirts and long pants and using insect repellants, window screens and mosquito bed nets along with removing potential sources by eliminating pools of standing water.

Insect repellants containing at least 20 percent DEET or picaridin are recommended and should be reapplied often. Permethrin-treated clothing including camping gear can be bought to provide extra protection.

Do this and your next vacation may not end with achy joints.