A 41-year-old male presented to the surgery outpatient department in Goa with a 2 day history of painful swellings on the left side of his neck with low-grade fever, malaise, and muscle pain of one day duration. There was no history of accompanying chills and rigor or rash. There were no ear, nose, and throat (ENT) or tooth complaints. There was no history of night sweats, loss of weight and loss of appetite. His past medical and family history was unremarkable. He had no history of tuberculosis (TB) or TB contacts. There was no recent history of foreign travel, insect bites, exposure to cats or other animals.
On presentation, his general condition was good, with an axillary temperature of 38 C. On physical examination, he had multiple lymph nodes located in posterior triangle of the neck on left side; the largest being approximately 2 x 1.5 cm in diameter. The lymph nodes were tender, mobile and firm in consistency with a smooth surface. He did not have any other site of significantly enlarged lymph nodes. Thyroid gland was not palpable. ENT examination was normal. Physical examination revealed no other abnormalities. A cervical ultrasound scan confirmed the examination findings and also demonstrated few subcentimetric lymph nodes in the posterior triangle of the neck on right side. Abdominal ultrasound revealed no abnormalities. He was given a course of oral amoxicillin/clavulanate combination, antipyretics, analgesics and was reviewed at the end of a week. There was no change in the symptoms or size of the lymph nodal mass. Hence, a fine-needle aspiration cytology (FNAC) was performed. But the cytological features were inconclusive.
The patient was referred to the medicine department with fever increasing to around 40 C. He was advised certain investigations and prescribed another course of antibiotic for 5 days. With this treatment, fever subsided but joint pains appeared after 2 days, first in the wrists and fingers followed by shoulders on both sides. The joint swelling was more at the wrist and fingers. Laboratory investigations revealed normal blood cell counts. The peripheral smear was normal without evidence of atypical lymphocytes. His erythrocyte sedimentation rate (ESR) was 18 mm/hr. Urine analysis and serum uric acid was normal. Search for malaria parasites, antinuclear and double-stranded DNA antibodies, and rheumatoid factor was negative. Serologic tests for hepatitis A, B, and C, human immunodeficiency virus (HIV) and syphilis were negative. The serology was negative for both dengue IgM and IgG antibodies (immunochromatography). The chikungunya IgM antibody was not detected by serum IgM ELISA. The purified protein derivative (PPD) test was negative. There was no evidence of focal lesion on chest radiograph.
After 5 days the lower extremity joints were involved with profound swelling and limitation of movement; the swelling being more at the ankle joint [Figure 1]. He also experienced severe degree of myalgia in the thigh region. Patient was started on non-steroidal anti-inflammatory drugs (NSAIDs) and local application of magnesium sulfate salt. With this treatment the swelling and pain significantly decreased. But the lymph node swelling on the left side persisted and one more lymph node swelling appeared on the right side [Figure 2]. Thus, an excision biopsy was performed, with removal of this enlarged cervical lymph node. Histopathological examination of biopsy revealed necrotizing lymphadenitis with reactive hyperplasia. There was no evidence of histiocytosis, tuberculoid granuloma, or malignancy. A diagnosis of chikungunya was made based on history elicited by the patient and clinical findings. The arthralgia and myalgia persisted for a total period of 3 months following acute infection.