Dear Terri

It is clear that in dengue, severe illness, including hemorrhagic manifestations, is more frequent in patients with secondary dengue infection. But with chikungunya there is lack of information, not just for that, but also for the implications of coinfection, which has been actually reported.

Another thing I think should be consider is that in chikungunya there would be also differences in the severity of manifestations, may be according to the genotypes. This would be partially explaning differences between countries.

I would like to attach three papers, may be you know the first:

1. Dengue virus serotype 4 and chikungunya virus coinfection in a traveller returning from Luanda, Angola, January 2014.

Parreira R, Centeno-Lima S, Lopes A, Portugal-Calisto D, Constantino A, Nina J.

Euro Surveill. 2014 Mar 13;19(10). pii: 20730.

2. Alfonso J. Rodríguez-Morales, Alberto E. Paniz-Mondolfi, Venezuela: Far from the path to dengue and chikungunya control, Journal of Clinical Virology, Volume 66, May 2015, Pages 60-61, ISSN 1386-6532, http://dx.doi.org/10.1016/j.jcv.2015.02.020.

3. J.R. Torres, L. Códova, J.S. Castro, L. Rodríguez, V. Saravia, J. Arvelaez, A. Ríos-Fabra, M.A. Longhi, M. Marcano. Chikungunya fever: atypical and lethal cases in the Western hemisphere: a Venezuelan experience. IDCases, 2 (2015), pp. 6–10

All of these files attached.

Finally, please if you consider this answer appropriate, please upvote it using the green up arrow click. Thanks.

Hi Alfonso,

Thanks for the 3 articles and the extensive knowledge you always provide. I had read the first 2 articles and was sure that you would respond with even more information and you did!

Thanks you and i have already clicked the green arrow. Upvote..Absolutely!  Terri

Thanks Terri.

Another interesting topic to propose research. In fact many things with chikungunya are to be studied!

Best wishes,

Alfonso.

Dear Terri and Alfonso,

although CHIKV can invade endothelial cells, these are clearly not its elective target cells to cause, Th1 cytokine-driven plasma leakage and related organ dysfunctions leading to hemorrhagic fever syndrome (as for Dengue). As Alfonso wrote, to date there have been to few co-infections documented so that from a public health point of view, it may seem impossible to answer. However, the introduction of CHIKV in areas where DENV is prominent (Americas, Pacific, SE Asia) offers a good opportunity to answer your question in a larger extent and the potential interactions between the two viruses is an exciting issue to be solved. From my experience, in La Réunion island (266,000 cases of CHIKV in 2005-2006), mild bleeding manifestations in the setting of CHIKV infection were not so infrequent, while clearly severe hemorrhages were scarce and decreased with age (neonates >> infants > children > adults) or occur in adults with severe comorbidity (diabetes, alcohol-related hepatic dysfunctions, etc...). As a pediatrician involved in the first description of mother-to-child transmission of CHIKV, we documented hemorrhagic syndromes in neonates in the absence of bacterial, fungic or viral co-infections. Finally, even it may also depend on host factors, the interaction between the two pathogens remains to be explored (keeping in mind alphaviruses and flaviviruses are very different pathogens). I fully agree with Alfonso, many things with chikungunya are to be studied. Best wishes

pg

Dear all,

Just a quick comment to say that when we received at IRBA all the samples from St Martin at the time of CHIKV emergence in Dec 2013 (http://www.sciencedirect.com/science/article/pii/S0140673614601859), we documented the number of DENV-CHIKV co-infection. We found a percentage of 2.8% of such patients (http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=20753), which is similar to what was described during a Gabon outbreak.

Regards

I fully agree with Patrick. And I don't know if these discussion may would be the beginning of a potential cooperation, because as has been pointed out, further studies of such interactions, influence of previous dengue and other vascular and non-vascular, related factors, would be of high interesting during the current outbreak in the Americas. We can provide clinical information, samples, as well be part of a research looking into these aspects discussed here. By the way Patrick, congratulations for excellent research and papers published in children with CHIK. I was really surprised and concerned about your paper in PLoS NTDs about Neurocognitive outcome of children exposed to CHIK in pregnancy. In fact we have submitted in the very recent past days, our experience with the first congenital CHIK cases here in Colombia. Dear Christine, thanks for your comment, I am also aware of your research. Very interesting, congratulations too. Best wishes to all of you, Patrick, Terri and Christine. 

Hi Alfonso, Patrick and Christine,

I have thoroughly enjoyed the stimulating feedback from all of you, clearly based on knowledge and experience with dengue and CHIKV and thanks for the articles, links, and future areas of research to pursue.  We all agree that  ChIKV is important to pursue

and there are so many interesting areas to look into, and I agree with Alfonso that it would be a very productive and potential cooperation.  I will be leaving for Panama

on Monday for some field work and have been working in KunaYala since the early 80s.

Although my funding is usually for ectoparasitic infestations, everything gets infected with Strep. that is often the cause of death in children.  Of course they also have worms, lice, fungal infections, nodular and every type of scabies, coral or sea urchin

spines in their hand or feet. I've been there for typhoid outbreaks, and we have been funded by AID for Cholera education when it was moving up the Magdelena river from Colombia and made educational film strips in their our Indian dialect using a sheet and solar projector. The first time they had been to a movie.  We also worked with WHO to determine which gel batteries , vaccine refridgerators would be used worldwide.   I had Mansonella ozzardi which Gorgas couldn't figure out what I had, I just knew when  they took my blood it was black and the Culicoides were so bad.Just Kept catching C furens.  Meanwhile my parasitology book said that only M. perstans can be harmful and M.ozzardi has just been found on autopsy.

DEC didn't do anything and when I brough my baby marmoset back, the tropical animal vet called up saying she has worms in her blood. I said are the sheathed or not?  Ivermectin cured us both!  I know that CHIKV has increased in Panama so I'll get more info when I'm there working with the Ministry of Health.

Thank you all for all the valuable information!

Terri

Interesting Terri. I have read and probably all you did, the first paper from Gorgas Institute in Panama on CHIK, which is in advance publication at AJTMH few days ago. In any case attached.

Best wishes,

Alfonso.

Alfonso,

Sorry for the delay but thanks for the Gorgas paper on CHIKV.  I may have mentioned that I got a travel alert of 16 confirmed cases the morning I was leaving for Panama,which was March 30 th.   A few of my Kuna friends (Dr. & RN) that work for the Ministry of Health at the Ailigandi Hospital in San Blas met me at the airport in Panama City since it was a Holiday break.  They knew of the alert but said that CHIKV is just in the City, not on the Caribbean Coast. They said that the malaria & dengue in San Blas is really  bad and they hadn't seen it like that for decades.  When we fly small planes from Panama city to jungle airstrips on the other coast, there are 500 miles of uncharted Darien jungle that are very mountainous and dense. There is no electricity except small aplication solar, or a generator for emergencies at the hospital and  little if any no communication between the 2 coasts. Occasionally we might get a radio station in Colombia. We never knew what was going on in Panama City, we were oblivious to riots in the streets, burning down the Bank of America, US invasions,etc. We usually didn't work near the hospital, because we were doing scabies and head lice studies and would go to mainland jungle villages with no medical care and severe cases of everything and more insects.  When we would go to another village for a week for follow ups or Panama to resupply, we would return and people, usually young children , would have had a high fever sometimes with seizures and would die. I know some were Strep. pyogenes, True cause usually unknown.  I wonder how much the increase in malaria and dengue might actually be CHIKV.  Most people don't go to the hospital since it requires a boat & motor & gas and there is no treatment anyway. The pharmacy is empty and the lab is not functioning as it once had and even if a blood smear showed P. vivax or falcip., there are no antimalarial in the pharmacy, so there is no reason to draw blood. It isn't being sent to Panama city or Gorgas.

With the Colombian boats constantly going up to KunaYala to trade sugar, hammocks, etc. and going back with coconuts, have you seen CHIKV in that coastal part of Colombia?

Considering the situation in Mombasa Island, Kenya where Dengue has been described as highly prevalent and the major CHIKV epidemic in 2004 spread here before emerging in the indian ocean islands, there has not been any cases of hemorrhage associated with CHiKV infections. However, available case descriptions are few but it could be that clinical phenotypes could also be influenced by circulating strains, co-circulation with other alphaviruses like o'nyong nyong virus, host characteristics among other factors.

This is the topic that has caught my research interest whereby am trying to understand the various epidemiological and clinical aspects of CHIKV in Kenya for the past 25 years. looking forward to the final report

Dengue and chikungunya (CHIK) infections appear to be increasing in all parts of India. Aedes aegypti mosquitoes are common vectors for dengue virus (DENV) and CHIK virus (CHIKV). In areas where both viruses cocirculate, they can be transmitted together.

https://www.ncbi.nlm.nih.gov › pmc

Coinfection of chikungunya and dengue viruses: A serological ...