Medical Mystery: Fever and pain after a trip to the Caribbean

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The Caribbean beach vacation was great. The aftermath? Not so much

During my medical residency in Miami, I saw a 32-year-old woman  — who happened to be a Philadelphia lawyer – when she came to the emergency room with a high fever and severe joint pains. She and some friends had been on vacation in the Dominican Republic, but she felt so ill she cut her trip short. Her journey to Philadelphia involved a layover in Miami, but she felt so ill she had to leave the airport and go to the hospital.

She told me she had never had symptoms like this before – a general feeling of malaise; pain in her ankles, wrists, and feet; and a temperature that went as high as 103. I asked her what she had been doing on vacation, and she said mostly hanging out on the beach. She did notice there were some biting insects there. She denied any intravenous drug use or high-risk sexual encounters.

Her symptoms suggested a number of viral illnesses, including acute HIV infection and even dengue fever. Mosquito bites are also concerning for malaria. Her illness preceded the Zika outbreak, but today, I would have to add that to the list of considerations. Through a combination of tests and consideration of her symptoms, we narrowed the possibilities.


Solution

According to the World Health Organization, chikungunya is a mosquito-borne viral disease first described during an outbreak in southern Tanzania in 1952, but didn’t make its way to the Caribbean until late 2013. More recently, cases have been reported in Florida.

It’s a funny-sounding name to American ears, but there is nothing funny about the disease for those who have it. In fact, “chikungunya” comes from a word in the Kimakonde language that means “to become contorted” – due to joint pain.

The disease is extremely uncomfortable for most and can even be fatal for a  few. The disease occurs in warm and wet climes, where mosquitoes can breed and transmit the disease.

The typical presentation is the development of extremely painful joints and high fevers three to seven days after a bite from an infected mosquito. Other symptoms can include muscle pains, headaches, joint swelling, and a rash. Confirmation of the disease is done by blood testing. Fortunately for most, the disease is self-limited, lasting about a week.

Although there is no specific treatment or vaccine for the disease, most people make a full recovery with supportive care, which includes hydration and analgesics. In some cases, joint pain can persist for months to years. And rarely, death can occur, particularly in people who are older than 65 or have other health problems, like diabetes or cardiovascular disease.

Our patient was admitted for intravenous fluids and pain management and her fever was down  after a few days. Although the results were slow to come, her blood test showed the presence of the chikungunya virus. Her condition improved and she continued her journey home.

The Philadelphia region is no stranger to mosquito-borne illness – consider the huge impact that yellow fever had on the city in the 18th century. Chikungunya is not a risk here, but the West Nile virus is a real danger, as is tick-borne Lyme disease. So as the weather warms up, take steps to protect yourself and your family from bug bites, including using insect repellent and wearing long pants and sleeves when outdoors, particularly during dawn and dusk.

Shivam Joshi, M.D., is a fellow of clinical nephrology in the Perelman School of Medicine at the University of Pennsylvania. Find him on Twitter @sjoshimd.