Recommendations
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A. Clinical, laboratory and imaging diagnosis
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A.1. Possible occurrence of Chikungunya fever should be strongly considered in cases with acute fever, severe joint pain/arthritis with or without exanthema within the context of an epidemic. However, other acute febrile diseases ought to be considered in the differential diagnosis, especially as concerns severe or atypical cases. Concordance: 9.31 (SD
±
1.168); level of evidence (2-4)
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A.2. In patients with clinical suspicion of acute Chikungunya fever, laboratory assessment (complete blood count, liver enzymes, creatinine, fasting glycemia, erythrocyte sedimentation rate (ESR)/CRP) should be decided on a case-by-case basis according to comorbidities and signs of severity. Concordance: 7.12(SD
±
3.5); level of evidence (3,4)
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A.3. CHIKV should only be investigated in cases for which diagnostic confirmation at the acute stage is needed: atypical cases, differential diagnosis in the case of severe presentation or to establish public health policies (suspicion of new foci or post-epidemic cases), in which case the first-choice method is real-time PCR that should be performed within the first week of the appearance of symptoms. Concordance: 9.19 (SD
±
0.839); level of evidence (2,3)
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A.4. Relative to acute cases of Chikungunya fever, serology (ELISA) for CHIKV (IgM and IgG) should only be performed in cases with atypical presentation or when differential diagnosis is needed; in such cases, it should be performed after the tenth day since the onset of symptoms. Relative to chronic cases, serology is recommended for the purpose of confirmatory diagnosis, but not to start treatment. Concordance: 9.29 (SD
±
1.510); level of evidence (2-4)
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A.5. During the chronic stage of Chikungunya fever, autoantibodies should only be investigated when differential diagnosis with specific rheumatologic diseases is necessary with compliance with the available consensuses/guidelines. Concordance: 8.55 (SD
±
2.593); level of evidence (3,4)
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A.6. In the acute and subacute stages of Chikungunya fever, most patients do not need imaging tests. In the chronic stage of disease, plain radiography should be requested by the rheumatologist on the first visit for initial structural and preexisting damage assessment. Concordance: 9.70 (SD
±
0.651); level of evidence (3,4)
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A.7. Musculoskeletal ultrasound might contribute to the assessment of joint and periarticular abnormalities at any stage of Chikungunya fever. In the acute stage of disease, it is the only imaging test that might be performed according to the doctor's opinion, being particularly useful for the differential diagnosis of lower limb swelling. Concordance: 9.29 (SD
±
1.510); level of evidence (3,4)
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B. Special situations
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B.1. In the treatment of pregnant women with Chikungunya fever, the risk posed by medicines to the fetus should be taken into account; when indicated, analgesics, prednisone/prednisolone and hydroxychloroquine may be used. Concordance: 9.71 (SD
±
0.534); level of evidence (3,4)
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B.2. By itself, Chikungunya fever is not an indication of cesarean section, the need of which should be established on obstetrical grounds only. Breastfeeding is allowed. Concordance: 9.67 (SD
±
0.547); level of evidence (3-4)
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B.3. Relative to the elderly (>60 years old) with Chikungunya fever, strict clinical monitoring of medications, comorbidities and higher risk of complications is recommended at all stages of disease, the acute stage in particular. Concordance: 9.61 (SD
±
0.737); level of evidence (3,4)
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B.4. Children under 2 years old should receive special attention due to their higher risk of severe and atypical manifestations, involvement of the central nervous system (CNS) in particular. Concordance: 9.30 (SD
±
1.179); level of evidence (3,4)
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B.5. Newborn infants from mothers with clinical manifestations suggestive of Chikungunya fever close to labor should be subjected to close observation along the first 5 days of life. Rational use of medications should be performed for cases that develop disease; complex cases should be managed at the intensive care unit. Concordance: 9.54 (SD
±
0.838); level of evidence (3,4)
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B.6. Treatment for the acute stage of Chikungunya fever in children consists of hydration, analgesics and antipyretic agents; salicylates should be avoided. For the chronic stage, we suggest following the recommendations for adults, while taking the particularities inherent to this age range into account. Concordance: 9.48 (SD
±
0.785); level of evidence (3,4)
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B.7. We recommend paying special attention to patients with previous diagnosis of rheumatoid arthritis, spondyloarthritis or systemic lupus erythematosus, as these conditions might become reactivated or exacerbated. Concordance: 9.42 (SD
±
1.840); level of evidence (3,4)
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