Severe sepsis and septic shock associated with Chikungunya infection in children

Abstract

Background : Chikungunya fever has unexpectedly re-emerged in the form of epidemics in many tropical African and Asian countries. Delhi witnessed worst epidemic of chikungunya fever in year 2016. It is benign diseases with few complicated or severe manifestation reported previously. Methods : Study design: retrospective observational The study population included all PCR positive cases of Chikungunya admitted from September 2016 to December 2016 in PICU. The information recorded included demographic features, clinical features, laboratory parameters, hospital stay and mortality. Results : Of the 49 children with PCR positive chikungunya, 36 had common form and 13 had severe disease. In severe group, 11 had illness consistent with case definition of severe sepsis and septic shock and rest 2 had acute liver failure. Though not statistically significant we observed that the two age groups (< 1 year and 11-14 year) had more likely to have severe form. There was male preponderance in both forms. Frequency of fever, body ache, arthralgia and vomiting were similar in both forms. Although not significant rash, bleeding manifestations and abdominal pain was more common in severe disease and seizures were more in non-severe form. Peripheral cyanosis along with mottling of skin was significantly higher in severe disease (76.9% vs 5.5%; p- 0.00). Values of haemoglobin, platelet counts, serum urea, creatinine and alanine and aspartate transaminase were similar. Total leukocyte count was higher in severe form (median 11200 vs 8195) although not significant. The serum albumin was significantly low in severe form (3 vs 3.75g/dl). Median PT, INR and aPTT in severe form were 22.3s (18.5-117), 1.77(1.3-12.4) and 41.7s (27-247) respectively. Hospital days were significantly high in severe form (5 vs 3, p-0.0015). In the severe form, 23% required mechanical ventilation and 84.6% required inotropic support. One, 2 and 3 vasoactive agents were used in 6, 3 and 2 children respectively. Dopamine was used in 8 followed by dobutamine in 5, and epinephrine and norepinephrine in 2 cases each. Median duration of inotropic support was 56 hours(31-114hours) and median Vasoactive Inotropic Score (VIS) in first 24 hours was 10(5-90). VIS score of >20 was seen in two cases. Mean pH, lactate and mixed venous saturation was 7.26, 5.1mmol/L, was 55%. respectively. Two children also had multiorgan failure and one expired. Out of 2 ALF cases one had stage III and another had stage II hepatic encephalopathy. One of these had coinfection with dengue virus and another hepatitis E virus. Conclusion : Although chikungunya usually has a mild course, severe life-threatening complications can develop during the acute phase of the disease. In our study, none of the septic shock patients had another organism identified as a potential cause of sepsis. This finding strongly suggests chikungunya virus can cause severe sepsis and septic shock in children. Although we observed two age groups as risk factors for severe forms further, studies are required especially in paediatric population.