Dengue, chikungunya and zika arbovirus infections in Caribbean children

Abstract

Purpose of review: Dengue, chikungunya and zika have caused significant epidemics in the Caribbean in recent years. This review highlights their impact in Caribbean children.

Recent findings: Dengue has been increasingly intense and severe, seroprevalence is 80-100% in the Caribbean, children have increased attributable morbidity and mortality. Severe dengue, especially dengue with haemorrhage was significantly associated with haemoglobin SC disease and multiple organ-systems involved. These included the gastrointestinal and haematologic systems with extremely high lactate dehydrogenases and creatinine phosphokinases and severely abnormal bleeding indices. Despite appropriate interventions, mortality was highest within the first 48 h of admission. Chikungunya, a togavirus, affected 80% of some Caribbean populations. Paediatric presentations included high fever, skin, joint and neurological manifestations. Children less than 5 years of age had the highest morbidity and mortality. This maiden chikungunya epidemic was explosive and overwhelmed public health systems. Zika, another flavivirus, has a seroprevalence of 15% in pregnancy, so the Caribbean remains susceptible. Paediatric complications include pregnancy losses, stillbirths, Congenital Zika syndrome, Guillain-Barre syndrome, acute disseminated encephalomyelitis and transverse myelitis. Neurodevelopment stimulation programs for zika-exposed infants have been effective in improving language and positive behaviour scores.

Summary: Caribbean children remain at risk for dengue, chikungunya and zika, with high attributable morbidity and mortality.

Box 1

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FIGURE 1

Skin and joint manifestations in hospitalized Jamaican children with chikungunya fever key: erythematous patches of the dorsum of the foot and distal lower limb and oedema and erythema of the joints of the left great toe – infant (a), numerous vesicular lesions (early phase) and macular hyperpigmented lesions (late phase) of the abdominal wall – infant (b), hyperpigmented macules on the abdomen – infant (c), bullous lesions of the extensor surface of the lower limbs and denudation and hyperpigmentation of the diaper area – infant (d), arthritis, left second toe, infant (e), desquamation of the skin, infant (f), erythematous papular rash with desquamation of the shoulder – older child (g), erythematous papular rash (h), urticarial rash of the chest and abdomen – older child (i), erythematous maculopapular rash of the chest and abdomen – older child (j).

FIGURE 2

Panels (a, b, c above) show female infant at age 6 weeks (sucking at mother's breast), showing severe microcephaly, sloping fore-head, facial disproportion with ‘over-sized’ facial features, appearance of proptosis, horizontal nystagmus with bilateral optic atrophy. Infant also displays clenched upper limbs with cortical fisting, diastasis of ‘recti abdomini’ muscles, severe arthrogryposis and ‘rocker bottom’ feet. Panels (d and e, above) reveal infant's MRI of the skull and brain displaying marked microcephaly, collapsed skull bones with extensive scalp folding. There is decreased hemispheric parenchymal volume loss with decreased salvation and evidence of calcification (d). There are septations in the occipital horns of the lateral ventricles as well as evidence of a vermian hypoplasia, in keeping with a Dandy Walker variant. Mother gave signed, written, informed consent with her permission for these photographs to be used for the purposes of medical education, publication and research.

FIGURE 3

(a) An axial T2 fluid-attenuated inversion recovery (FLAIR) MRI brain showing high signal intensity of the right crus cerebri (yellow arrow). (b) T2-weighted sagittal MRI of the cervical and thoracic spine showing high signal intensity C2 to T4.