Recurrent arthralgias in a patient with previous Mayaro fever infection.

Abstract: Mayaro fever is an acute, self-limited, febrile, mosquito-borne viral disease manifested by fever, chills, headache, myalgias, and arthralgias. The virus belongs to the family Togaviridae and the genus Alphavirus. Five other mosquito-borne viruses have been described as causing a similar dengue-like illness. The virus was first isolated in 1954, and the first epidemics were described in 1955 in Brazil and Bolivia. Other cases have been reported in Suriname, Brazil, Peru, French Guiana, and Trinidad. Up to 10 to 15% of febrile illnesses in endemic areas have been attributed to Mayaro virus. The exact pathogenesis and pathophysiology among humans is unknown. Animal models have demonstrated necrosis of skeletal muscle, periosteum, perichondrial tissues, and evidence of meningitis and encephalitis. All previous cases of Mayaro fever describe a self-limited illness. No reports of recurrent symptoms exist in the literature. This report describes a case of recurrent arthralgias in a military service member presenting to the emergency department.

Key Words: arthropathy, Mayaro, military medicine, mosquito-borne, tropical medicine

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Mayaro fever is a mosquito-borne viral illness that is endemic in rural areas of South America near tropical rain forests. (1,2) Typical clinical manifestations include the abrupt onset of fever, chills, headache, myalgias, and arthralgias, and during a 2- to 4-day course may also include epigastric pain, backache, nausea, vomiting, photophobia, vertigo, dizziness, eye pain, rash, and diarrhea. The arthralgias are typically the most severe and prominent manifestation, are often temporarily incapacitating, and may persist for up to 2 months. In addition to Mayaro, five other mosquito-borne alpha-viruses have been described as causing a similar, dengue-like illness. (3,4) Cases of outbreaks and epidemics of Mayaro fever confirmed by virus isolation or serology testing have been documented in Trinidad, Suriname, Brazil, Bolivia, French Guiana, and Peru. (1,5,6-8) There are no specific measures to prevent the disease. Prevention includes avoiding mosquito bites in endemic areas by using protective clothing, barriers, and repellents. Treatment is symptomatic, and no vaccine is available. (3)

Case Report

A 39-year-old Hispanic male presented to a military emergency department with chief complaints of left hip, knee, and ankle pain. The patient was a retired Special Forces Master Sergeant who had the same symptoms as part of his clinical course in 1999 when he was diagnosed with Mayaro fever during a deployment to Bolivia. His diagnosis was suspected clinically by a host nation physician and confirmed by serology testing during the original manifestation. He described similar recurrences of arthralgias approximately every 6 months since the resolution of his original presentation. Medical history included hyperlipidemia. Surgical history included appendectomy. Allergies included a rash with cephalexin. Medications included indomethacin, tramadol, and methocarbamol when needed for joint symptoms and simvastatin daily. Social history included occasional smoking and alcohol use and was negative for illicit drug use. Family history included adult-onset diabetes, hypertension, cerebrovascular accidents, and hyperlipidemia. Family history was negative for inflammatory joint disease, crystal arthropathies, or autoimmune disorders.

The patient presented because his pain was not controlled by his take-as-needed medications. His vital signs were normal. History and review of systems revealed no recent trauma, illnesses, bites, camping, or recent foreign travel. Physical examination revealed normal vital signs, tenderness of the hip, knee, and ankle, including axial load pain, and no evidence of trauma, warmth, erythema, or edema. The extremity was neurovascularly intact and without ligamentous instability. Recent plain radiographs revealed mild degenerative joint disease symmetric with the contralateral extremity. The patient had previously undergone workup and laboratory analysis by his primary care provider for other arthropodborne arthropathies, autoimmune disorders, inflammatory joint disease/crystal-induced arthropathies, and sexually transmitted diseases, which were negative. The patient had no myalgias with the arthralgias, and his intermittent symptoms had occurred previous to starting simvastatin. A review of the prescription computer entry system was negative for drug-seeking behavior. The patient's symptoms were resolved with narcotic analgesics and he was discharged home. Follow-up care was arranged with his primary care provider, and a routine infectious disease consult was entered.

Discussion

This patient presented with arthralgias exactly like those he had during an episode of Mayaro fever contracted in Bolivia in 1999. He had four previous episodes identical to this approximately 6 months apart since his initial symptoms resolved. No other cause for these symptoms was found during his visit. Previous evaluation by his primary care provider for a broad differential was also negative. No other literature exists describing recurrent, non-self-limited symptoms for Mayaro fever. We propose that this patient's symptoms may be attributed to this cause. This is the first reported case in the literature of chronic or recurrent arthralgias caused by Mayaro fever virus. Recurrent arthralgias in a patient with Ross River virus have been described for several months after resolution of fever and other acute symptoms. (9) Residual joint symptoms for several years have been described in some patients after Chikungunya virus infection. (10,11) Mayaro fever is somewhat prevalent in certain foreign countries but is relatively obscure to US practitioners. The pathophysiology is poorly understood in humans at this point. We suggest that there remains much unknown and unreported information regarding the disease course and pathophysiology of mosquito-borne alpha-viral arthropathies such as Mayaro, Chikungunya, O'Nyong, Ross River, Sindbis, and Barmah Forest at this point.

Accepted June 21, 2004.

References

1. Talarmin A, Chandler LJ, Kazanji M, et al. Mayaro virus fever in French Guiana: Isolation, identification, and seroprevalence. Am J Trop Med Hyg 1998;59:452-456.

2. Tesh RB, Watts DM, Russell KL, et al. Mayaro virus disease: an emerging mosquito-borne zoonosis in tropical South America. Clin Infect Dis 1999;28:67-73.

3. McGill PE. Viral infections: alpha-viral arthropathy. Baillieres Clin Rheumatol 1995;9:145-150.

4. Tesh RB. Arthritides caused by mosquito-borne viruses. Annu Rev Med 1982;33:31-40.

5. Hoch AL, Peterson NE, LeDuc JW, et al. An outbreak of Mayaro virus disease in Belterra, Brazil, III: Entomological and ecological studies. Am J Trop Med Hyg 1981;30:689-698.

6. LeDuc JW, Pinheiro FP, Travassos da Rosa AP. An outbreak of Mayaro virus disease in Belterra, Brazil, II: Epidemiology. Am J Trop Med Hyg 1981;30:682-688.

7. Pinheiro FP, Freitas RB, Travassos da Rosa JF, et al. An outbreak of Mayaro virus disease in Belterra, Brazil, I: Clinical and virological findings. Am J Trop Med Hyg 1981;30:674-681.

8. Tavares-Neto J, Travassos da Rosa AP, Vasconcelos PF, et al. Research on antibodies to arbovirus in the serum of residents of the village of Corte de Pedra, Valencia, Bahia. Mem Inst Oswaldo Cruz. 1986;81:351-358.

9. Proll S, Dobler G, Pfeffer M, et al. Persistent arthralgias in Ross-River-Virus disease after travel to the South Pacific. Dtsch Med Wochenschr 1999;124:759-762.

10. Brighton SW, Simson IW. A destructive arthropathy following Chikungunya virus arthritis: A possible association. Clin Rheumatol 1984;3:253-258.

11. Brighton SW, Prozesky OW, de la Harpe AL. Chikungunya virus infection: A retrospective study of 107 cases. S Afr Med J 1983;63:313-315.

RELATED ARTICLE: Key Points

* Mosquito-borne alpha-viruses such as Mayaro fever present as a dengue-like illness with fevers and arthralgias.

* Outbreaks and epidemics of Mayaro fever confirmed by virus isolation or serology testing have been documented in Trinidad, Suriname, Brazil, Bolivia, French Guiana, and Peru.

* This is the first reported case in the literature of chronic or recurrent arthralgias caused by Mayaro fever, but recurrent arthralgias and residual joint symptoms have been reported in two other mosquito-borne alpha-viruses (Ross River and Chikungunya).

Shawn F. Taylor, MD, Paresh R. Patel, MD, and Thomas J.S. Herold, MD

From the Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, TX; the Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, TX; and the Department of Emergency Medicine, Darnall Army Community Hospital, Fort Hood, TX.

Reprint requests to Dr. Shawn F. Taylor, 11 Lakeview Drive, Whispering Pines, NC 28327. Email: [e-mail]