Vesiculobullous viral exanthem due to chikungunya in an infant.

Abstract

Sir, Chikungunya is an self-limiting arboviral disease caused by the chikungunya virus. It is transmitted mainly by the mosquito vectors Aedis aegypti and Aedis albopictus that breed in urban and semi-urban settings on clean standing (but stagnant) water.[1] Various dermatologic manifestations of chikungunya reported in infants include generalized erythema, maculopapular rash, vesiculobullous lesions, and skin peeling.[2] A 6-month-old child presented with high grade fever of three days and vesiculobullous rash of one day duration. Rash was initially erythematous and later turned dusky by the third day with associated blistering. Discrete, black flaccid vesicles and bullae were then noted on the trunk and perineum and spread to the extremities, sparing the face and mucosae [Figures ​[Figures11 and ​and2].2]. The child was otherwise unremarkable with no history of associated seizures, joint swelling, vomiting, or loose stools. There was no history of any medication intake prior to onset of blistering. Hemogram, liver function tests, renal function tests, and cerebrospinal fluid analysis were within normal limits. Blood culture and blister fluid culture were sterile. Serology for chikungunya by IgM antibody capture enzyme-linked immunosorbent assay (MAC-ELISA) (National Institute of Virology, Pune, India) was found to be positive from the serum sample sent on the sixth day of fever. An early vesicle was biopsied which on histopathological examination revealed intraepidermal bulla, dilated dermal blood vessels filled with fibrin and epidermal necrosis [Figure 3]. Child was treated symptomatically with paracetamol and fever subsided by the seventh day. Vesiculobullous rash started exfoliating by the sixth day and subsided completely without any pigmentary change by the tenth day. Figure 1 Purpuric vesicles and bullae over the trunk and extremities Figure 2 Purpuric vesicles and bullae over the gluteal region Figure 3 Histopathology of vesicle demonstrating intraepidermal cleft and dilated dermal blood vessels filled with fibrin and epidermal necrosis (H and E, ×100) In chikungunya, generalized erythematous rash develops abruptly during the first two days of fever followed by maculopapular rash in a centrifugal distribution on the second day of fever usually disappearing by the sixth day. Palms and soles are involved in around two-thirds of infants, but facial involvement is rare. Vesiculobullous eruptions in infants with chikungunya have been reported.[2,3,4] They usually present as sudden onset of flaccid vesicles and bullae usually on the fourth day of fever over the lower limbs that then spread to the perineum, abdomen, chest, and upper limb sparing the face and scalp. Lesions exfoliate by the sixth day and heal by the tenth day sometimes leaving behind pigmentary changes.[2] Clinical diagnosis can be confirmed by virus isolation, viral RNA by real-time polymerase chain reaction, virus specific immunoglobulin M antibodies by MAC-ELISA in a single serum sample collected in an acute state or four-fold increase in immunoglobulin G values in samples collected at least three weeks apart.[5] There is no specific antiviral therapy. Supportive treatment with paracetamol or other nonsalicylate analgesics is the mainstay of management. All suspected cases should be kept in mosquito nets during the febrile period and mosquito control measures should be adopted.[4] We report this case to highlight the interesting presentation of chikungunya in an infant in the form of vesiculobullous lesions. Chikungunya should be included in the differential diagnosis of febrile vesiculobullous eruption in infants.