Objective: Our goal is to describe a case of generalized acute myoclonus in a patient with Chikungunya virus (CHIKV) encephalitis.

Background: There have been an increasing number of reports of neurological complications related with CHIKV infection, especially encephalitis [1], but there are few descriptions regarding the association of CHIKV and movement disorders.

Method: We described a patient with encephalitis related to acute CHIKV infection presenting with generalized myoclonus and ataxia.

Results: A 60-year-old male patient from the Northeastern of Brazil presented with mental confusion, behavioral changes, and incoordination in walking in the past four days. The symptoms worsened and he was no longer able to walk independently. He had a history of hypertension, diabetes, and atrial fibrillation. On admission, he had fever and was partially oriented. Generalized myoclonus aggravated by touch in a fixed posture was detected. He also presented distal and symmetric bilateral tremor in the upper limbs and mild ataxia during the index–nose–finger test. His gait was broad-based and unstable. Complete blood cell count, metabolic panel and rheumatologic screen were unremarkable. CSF was collected four days after admission and revealed 3 lymphocytes, 74 mg/dl of protein and normal glucose levels. Brain MRI showed foci of FLAIR hypersignal in cortical, subcortical, and periventricular regions [figure 1]. EEG demonstrated mild to moderate slowing. A 5-day course of methylprednisolone pulse therapy was started with the initial hypothesis of autoimmune encephalitis, however, the patient evolved with pulmonary septic shock and acute kidney injury and died after 22 days of hospitalization. IgM ELISA for CHIKV was positive on plasma and CSF samples. Serological testing was negative other agents, including Dengue and Zika virus. Neurological complications of CHIKV infection may be severe, typically in elderly and in those with comorbidities [2]. Possible mechanisms involved in CHIKV encephalitis may involve a direct viral invasion of CNS tissue or an immune mediated response causing severe inflammation [3]. Movement disorders may be the presenting symptom, but the frequency of this occurrence is unknown [4,5].

Conclusion: The presentation of encephalopathy with fever and abnormal movements, especially myoclonus and cerebellar dysfunction, should raise the suspicion of severe CHIKV encephalitis in endemic areas.

References: 1. Brizzi K. Neurologic Manifestation of Chikungunya Virus. Curr Infect Dis Rep. 2017 Feb;19(2):6. doi: 10.1007/s11908-017-0561-1. PMID: 28233188.

2. Mehta R, Gerardin P, de Brito CAA, Soares CN, Ferreira MLB, Solomon T. The neurological complications of chikungunya virus: A systematic review. Rev Med Virol. 2018 May;28(3):e1978. doi: 10.1002/rmv.1978. Epub 2018 Apr 19. PMID: 29671914; PMCID: PMC5969245.

3. Cerny T, Schwarz M, Schwarz U, Lemant J, Gérardin P, Keller E. The Range of Neurological Complications in Chikungunya Fever. Neurocrit Care. 2017 Dec;27(3):447-457. doi: 10.1007/s12028-017-0413-8. PMID: 28741102.

4. do Rosário MS, Giovanetti M, de Jesus PAP, Farias DS, Faria NR, de Lima CPS, da Silva SP, Nunes MR, Alcantara LCJ, de Siqueira IC. Opsoclonus-myoclonus-ataxia syndrome associated with chikungunya and dengue virus co-infection. Int J Infect Dis. 2018 Oct;75:11-14. doi: 10.1016/j.ijid.2018.07.019. Epub 2018 Aug 1. PMID: 30076990.

5. Kalita, J., Kumar, P. & Misra, U.K. Stimulus-sensitive myoclonus and cerebellar ataxia following chikungunya meningoencephalitis. Infection 41, 727–729 (2013). https://doi.org/10.1007/s15010-013-0406-2.

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MDS Abstracts - https://www.mdsabstracts.org/abstract/generalized-acute-myoclonus-caused-by-chikungunya-virus-encephalitis-case-report/