GUILLAIN-BARRÉ SYNDROME AFTER CHIKUNGUNYA VIRUS INFECTION

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Rev. Augustus | Rio de Janeiro | v.23 | n. 45 | p. 173-178 | jan./jun. 2018 173

Marco Orsini* UNISUAM orsinimarco@hotmail.com Denise Flávio de Carvalho** Centro de Atenção em Saúde Funcional Ramon Pereira de Freitas

denise.flavio40@globo.com José Teixeira de Seixas Filho***

UNISUAM seixasfilho@yahoo.com.br Rossano Fiorelli**** Universidade de Vassouras fiorelliorossano@hotmail.com Eduardo Lima Trajano*****

Universidade de Vassouras eduardolimatrajano@hotmail.com

ABSTRACT

Background: In Brazilian territory, the most common arboviruses are DENV (Dengue), CHIKV (Chikungunya), and ZIKV (Zica), although others may spread in the country. These arboviruses has also resulted in a number of neurologic diseases such as Guillain-Barré syndrome, meningoencephalitis, myositis and cranial nerve palsies. This article reports the

*_{Programa de Mestrado Em Ciências Aplicadas a Saúde. Universidade de Vassouras, Vassouras, RJ. Brasil} Programa Profissional de Mestrado em Desenvolvimento Local. UNISUAM.

**_{Centro de Atenção em Saúde Funcional Ramon Pereira de Freitas, Nova Iguaçu, RJ. Brasil}

***_{Possui graduação em Licenciatura e Bacharelado Em Ciências Biológicas pela Fundação Técnico Educacional} Souza Marques (1981), mestrado em Zootecnia pela Universidade Federal de Viçosa (1990), doutorado em Zootecnia pela Universidade Federal de Viçosa (1998) e Pós-doutorado em Bioquímica/Enzimologia pelo Instituto de Biotecnologia Aplicada à Agropecuária - BIOAGRO - da Universidade Federal de Viçosa (2008). Pesquisador aposentado da Fundação Instituto de Pesca do Estado do Rio de Janeiro. Atualmente é Professor Titular do Centro Universitário Augusto Motta, Coordenou o Mestrado Multidisciplinar em Desenvolvimento Local da UNISUAM (2008-2010) onde Desenvolve pesquisas em inserção social, cadeias produtivas sustentáveis, recursos hídricos e análises socioeconômicas em populações vulneráveis.

****_{Programa de Mestrado Em Ciências Aplicadas a Saúde. Universidade de Vassouras, Vassouras, RJ. Brasil}

*****_{Programa de Mestrado Em Ciências Aplicadas a Saúde. Universidade de Vassouras, Vassouras, RJ.}

Graduado em fisioterapia pela Universidade Severino Sombra (USS) em 2008 realizou mestrado (2011) e Doutorado (2015) na Universidade do Estado do Rio de Janeiro (UERJ) no programa de Biologia Humana e Experimental atuando diretamente em projetos com ênfase em doenças pulmonares obstrutivas crônicas (DPOC), estresse oxidativo, reparo cutâneo em queimaduras, dano de DNA e laser terapêutico. É supervisor de estágio na área de eletrotermo fototerapia no curso de fisioterapia e professor adjunto II Universidade de Vassouras desde 2011 tendo lecionado disciplinas no ciclo básico e disciplinas aplicadas.

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case of a woman, 33 years that suddenly developed shooting fever, muscle pain and ascedent weakness, receiving subsequently the diagnosis of guillain-barré syndrome for probable unspecified viral infection. After a few days of hospitalization, the diagnosis of Guillain-Barre by possible CHIKV fever were confirmed across clinical evaluation, cerebrospinal fluid, electrophysiological findings and the specific titles of IgM for CHIKV. Months after treatment with intravenous immunoglobulin remains with muscle weakness in lower limbs and difficulties in performing daily activities. The article becomes important because chikungunya infection causes a high number of affected individuals, with severe cases (as presented), and implications for health services, mainly due to the absence of specific treatment, vaccines, and effective prevention and control measures.

Keywords: Chikungunya Fever. Arbovirus Infections.Guillain-BarreSyndrome. Emerging.

SÍNDROME DE GUILLAIN-BARRÉ APÓS INFECÇÃO POR VÍRUS DE

CHIKUNGUNYA

RESUMO

Antecedentes: No território brasileiro, os arbovírus mais comuns são o DENV (Dengue), o CHIKV (Chikungunya) e o ZIKV (Zica), embora outros possam se espalhar pelo país. Esses arbovírus também resultaram em várias doenças neurológicas, como síndrome de Guillain-Barré, meningoencefalite, miosite e paralisia de nervos cranianos. Este artigo relata o caso de uma mulher de 33 anos que desenvolveu repentinamente estado febril, dor muscular e fraqueza ascendente, recebendo subsequentemente o diagnóstico de síndrome de Guillain-Barré para provável infecção viral não especificada. Após alguns dias de hospitalização, o diagnóstico de Guillain-Barré por possível febre do CHIKV foi confirmado através de avaliação clínica, líquido cefalorraquidiano, achados eletrofisiológicos e títulos específicos de IgM para o CHIKV. Meses após o tratamento com imunoglobulina intravenosa permanece com fraqueza muscular nos membros inferiores e dificuldades na realização de atividades diárias. O artigo torna-se importante porque a infecção por chikungunya causa um número elevado de indivíduos afetados, com casos graves, como apresentados, e implicações para os serviços de saúde, principalmente devido à ausência de tratamento específico, vacinas e medidas eficazes de prevenção e controle.

Palavras-chave: Febre Chikungunya, Infecções por Arbovirus, Síndrome de Guillain-Barré, Emergentes.

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1 INTRODUCTION

In recent years, CHIKV has gained attention due to its quick spread in the Americas, with many cases reported between 2014 and 20171. Chikungunya fever is a globally spreading mosquito-borne disease that shows an unexpected neurovirulence. Systemic and neurological complications have been reported with CHIKV2. Guillain-Barré syndrome (GBS) is a rare neurological complication which may occur after subsidence of fever and others symptoms by several neurotropic viruses3. Diseases caused by these viruses are of great public health relevance, however, their epidemiological features in areas where the three viruses co-circulate are scarce. We report one case of (GBS) with CHIKV.

CASE REPORT: JAS, 33 years old, Caucasian, domestic, had been treated at Hospital of the Northern Zone in Rio de Janeiro on 03 \ 03 \ 2017. The initial clinical picture was marked by lancinating headaches, bilateral and symmetrical polyarthralgia, muscle weakness, macular rash and fever. She received symptomatic treatment, performed laboratory tests and was released with a possible non-specific viral disease.

After 48 hours he returned with complaints of inability to walking and muscle weakness in the four limbs, especially in the lower limbs. The neurological examination presented a flaccid paraparesis and absence of deep reflexes. Sensory Disturbances (tactile, thermal and painful hypoaesthesia in the distal third of the limbs and hypopasthesia, were also present). No signs of pyramidal pathway injury were identified. Clinical investigation started with a complete blood count (Leukopenia, Erythrocyte sedimentation rate (ESR), CRP (C-reactive protein) in addition to creatine phosphokinase (CPK).

The findings of magnetic resonance imaging of the skull and thoracic and lumbar spine were not related to the clinic presented., Electronuromyography (ENM) was compatible with peripheral neuropathy, affecting distal and proximal structures with involvement of sensory and motor fibers and with axonal damage characteristics. Liquor examination revealed albino-cytologic dissociation and pleocytosis (consisting of lymphocytes and monocytes).

The presence of oligoclonal bands was not identified. The laboratory diagnosis of CHIKV-IGM infection was also identified in the Brain-Spinal Fluid, with negativity for Dengue

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and Zica. After the ninth day of hospitalization, a new hemogram was identified IGM antibodies to CHIKV.

Initiated clinical treatment with intravenous immunoglobulin for 5 days, after 72 hours from the beginning of the clinical picture. He was discharged. There is still a motor sequel to the lower limbs - paraparesis.

2 DEVELOPMENT

Chikungunya (CHIKV) is a RNA virus of the Togaviridae family of the genus Alphavirus, first described in 1950 in the region that today corresponds to Tanzania, which is characterized by fever pictures associated with intense and debilitating joint pain, headache and myalgia. It presents dengue-like symptoms but includes symmetrical polyarthritis e arthralgia, mainly wrists, ankles and elbows (AGRAWAL et al. 2017).

According to Powerset al. (2007) the name Chikungunya means "one who bows" in the Makonde language, spoken in various parts of East Africa, the reason for the antalgic position that patients acquired during the period of illness. According to Donalisio and Freitas (2015), a higher proportion of symptomatic cases (> 90%), a shorter intrinsic incubation time, from 2 to 7 days, a longer viraemia period (2 before and 10 after fever) and shorter extrinsic incubation period, in the mosquito.

Although severe pictures are not so common, neurological manifestations (meningoencephalitis, convulsion, Guillain-Barré syndrome, cerebellar syndrome), ocular (optic neuritis, retinitis, uveitis), cardiovascular (myocarditis, pericarditis, heart failure, arrhythmia), cutaneous (nephritis, acute renal insufficiency), among others, have been observed (SILVA et al., 2018).

SGB is an autoimmune monophasic inflammatory polyradiculoneuropathy characterized by a rapid upward evolution of limb weakness, hypoflexia, or arreflexia, and celluloprotein dissociation in cerebrospinal fluid (CSF). The disease can reach maximum severity within four weeks, severe sequelae and death can occur (CERNY et al., 2017).

In the literature we find case descriptions of GBS by ZIKV infection rather than by CHIKV, as well as the fact that Chikungunya generally becomes asymptomatic after 10 days

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or that the joint pain may last for a few months. Recent studies of GBS caused by Chikungunya (SILVA et. al., 2018).

A great milestone is presented to the countries when we talk about CHIKV and GBS, it is necessary a great diffusion among health care networks. The occurrence of simultaneous epidemics is a reality and makes it difficult to handle cases (SILVA JR et al., 2018).

The Ministry of Health also points out the importance of early identification of cases in an indene area, extension of the diagnostic back and the training of health teams. The risk of establishing an enzootic Chikungunya cycle making it impossible to eradicate the disease in some countries is public health, so it is up to governments and the scientific community to seek ways to prevent this from becoming a reality (SILVA et. al., 2018).

To this end, a series of investigations have been carried out by the Ministry of Health in support of the State and Municipal Secretariats, in order to clarify the consequences of Zika virus infections. In the year 2015, in Pernambuco, in the northeastern region of Brazil, there was confirmation of the outbreak of Guillain-Barré syndrome, demonstrating that it is a plausible hypothesis that these cases described, as well as the increased incidence of Guillain-Barré syndrome, were associated with previous infections by Zika (NÓBREGA et al., 2018).

Guillain-Barré syndrome (GBS) is an autoimmune monophasic inflammatory polyradiculoneuropathy, characterized by a rapid ascending evolution of limb weakness, almost always symmetrical, hypo- or arreflexia, and celluloprotein dissociation in cerebrospinal fluid (CSF). The disease can reach maximum severity within four weeks, with the development of respiratory failure in approximately 25% of cases. Of these, most have completed recovery. However, severe sequelae and death can occur in up to 20% and 5% of cases, respectively (SEJVAR et al., 2011; WILLISON et al., 2016).

3 FINAL CONSIDERATIONS

Guillain-Barré syndrome (GBS) is a disease of autoimmune origin, in which antibodies are produced against the myelin sheath, causing severe damage to this structure, compromising the ability to move, sensitivity, causing generalized muscle weakness, that in more severe cases, it can paralyze respiratory muscles.

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Epidemiologic data support a causal relationship between chikungunya infection and GBS.In the absence of an effective treatment, patients should receive supportive care for classic GBS.

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