Abstract Introduction Chikungunya Fever (CHIKF), caused by the Chikungunya Virus (CHIKV), is typically a benign illness characterized by fever, rash, and polyarthralgias. While the mortality of CHIKF is low, severe complications may occur. Systemic Capillary Leak Syndrome (SCLS), defined by the triad of hemoconcentration, hypoalbuminemia, and hypotension, is a rare but fatal consequence of CHIKF. We describe a fulminant case of CHIKV induced SCLS resulting in refractory shock and multi-organ failure. Case Description A 50 year old man with a history of hypothyroidism presented after 4 days of fever, rash, and arthralgias that began in Bangladesh. RT-PCR testing confirmed acute Chikungunya viremia (IgM/IgG negative) and was negative for Dengue/Zika. On presentation, he was tachycardic (HR 141 BPM) and normotensive (BP 115/72). Initial labs showed hemoconcentration (Hgb 19.8 g/dL; HCT 58.8%), acute kidney injury (SCr 2.3 mg/dL, K + 6.7 meq/L), transaminitis (AST 268 U/L), and high anion gap metabolic acidosis (Bicarbonate 12 meq/L, Lactate 7.40 mmol/L). Despite fluid resuscitation and empiric antibiotics, he rapidly decompensated necessitating intubation. He developed refractory shock requiring maximal vasopressor therapy (norepinephrine, epinephrine, vasopressin, phenylephrine). The fluid strategy was broadened to include crystalloid and colloid replacement; however, the patient’s lactic acidosis progressed (pH 7.22, Lactate 10.5 mmol/L). Given the refractory vasoplegia, a loading dose of Methylene Blue was administered without any impact on pressor requirements. Hemodialysis was also initiated due to decompensated kidney failure (SCr peak 4.1 mg/dL). Laboratory analysis confirmed the triad of SCLS (Hemoglobin peak 20.4 g/dL; HCT peak 61.6%; Albumin nadir 1.9 g/dL). Despite maximal life support measures, the patient expired after succumbing to multi-organ failure after 36 hours under ICU care. Discussion CHIKV can precipitate profound endothelial dysfunction and cytokine mediated vascular leakage, mimicking Dengue Shock Syndrome yet occurring during acute viremia without immune priming. This case demonstrates that current measures (aggressive resuscitation, vasopressor support, HD, and methylene blue) are insufficient in aggressive, fulminant cases of CHIKF induced SCLS. The use of steroids in acute viral infection is controversial; however, steroids have shown mortality benefit in severe COVID 19 infections. Therapeutic plasma exchange is another treatment modality that provides a theoretical benefit in clearing the plasma of excess cytokines. Further clinical investigation is needed to develop ideal strategies for management of viral induced SCLS, particularly in endemic and emerging regions. This abstract is funded by: None
Ahmed et al. (Fri,) studied this question.