Non-inflammatory blisters in the case of chikungunya

Description

A male toddler was brought by his parents to a dermatology consultation service for multiple cutaneous blisters on the lower limbs and perineum region that have been present for the past 3 days. The parents reported that the child had a few episodes of high-grade fever 4 days prior to the onset of blisters. During the illness, the toddler had poor oral intake of food and fluids. In the first 3 days of illness, the fever episodes responded to acetaminophen; however, later the fever no longer responded to acetaminophen. The parents also reported that the toddler did not move his lower limbs during the period of illness. The toddler and the parents hailed from a rural locality in Central India with poor sanitation facilities and an open sewage system infested by mosquitoes.

Cutaneous examination showed multiple non-inflammatory blisters on the inner thighs and inner calves (figure 1). In places, individual blisters coalesced to form a larger blister. The blisters had straw-coloured fluid. There were few erosions noticed around the perineal region. Tzanck smear from one of the blisters did not show acantholytic cells. Laboratory investigations showed low haemoglobin (9.6 g/L) and lymphopaenia (2200 cells/cu.mm). Viral serology was positive for IgM anti-chikungunya antibodies by ELISA method. Blood investigations for renal function and liver function were normal. The toddler was admitted to the paediatric care unit for a period of 10 days and was treated with supportive care (fluids, antipyretic and non-steroidal anti-inflammatory drugs). The cutaneous blisters healed with minimal pigmentary changes.

Figure 1.

Multiple non-inflammatory vesicles and bullae on the inner aspects of the thighs and calves. Few erosions are present on the perineal skin.

Chikungunya is an acute-onset viral disease transmitted to human beings by infected Aedes aegypti mosquitoes and characterised by high fever, myalgia and arthralgia, and skin rash. Various cutaneous manifestations, including morbilliform rash, maculopapular rash, bullous rash, nasal blotchy erythema, exfoliative dermatitis, epidermolysis bullosa-like lesions, intertriginous aphthous-like ulcers, purpura, vasculitic lesions, facial oedema, cutaneous pruritus (foot arch) and localised petechiae, have been described.^{1 2} Garg and colleagues³ have reported a case series of Stevens-Johnson syndrome and toxic epidermal necrolysis-like cutaneous presentation in chikungunya fever. A paediatric case series on small infants (eight boys and five girls) described severe, extensive bullous skin lesions needing intensive skin care with excellent outcomes.⁴ The blisters in chikungunya infection are intraepidermal and usually heal without scarring and minimal pigmentation. Although rare, a non-inflammatory blister on the lower limb and perineal region with straw-coloured fluid in a febrile patient can be considered a characteristic cutaneous sign of chikungunya fever.

Learning points.

• The cutaneous manifestations of chikungunya fever are varied with non-specific morphology.

• In a febrile patient, non-inflammatory blisters with straw-coloured fluid on the thighs and perineal region can be considered a diagnostic clinical feature of chikungunya infection.

• The blisters usually heal without scarring and minimal pigmentary changes.

Ethics statements

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Parental/guardian consent obtained.