Brief Original Article
Ribavirin therapy for Chikungunya arthritis
Rajan Ravichandran, Manju Manian. Madras Institute of Nephrology, Vijaya Heath Centre, N.S.K Salai, Chennai-600026, India.
Background: Chikungunya is an acute viral infection presenting with a febrile episode and severe arthralgia, swelling of soft
tissues, especially around the ankles. Many patients recover with nonspecific treatment of analgesics. Some patients continue to
have subacute crippling arthritis in the legs affecting their mobility. This study was undertaken to see the effect of the antiviral
drug Ribavirin in the clinical outcome of these patients.
Methodology: Ten patients who continued to have crippling lower limb pains and arthritis for at least two weeks after a febrile
episode were taken up for the drug study. Ten similar patients during the same period were included as controls. In the study
group Ribavirin was given at 200 mg twice a day for seven days. Both groups were followed up for four weeks
Results: All patients in the drug group reported improvement in the joint pains with six of them capable of walking freely. The soft
tissue swelling also reduced in eight. In three patients the pain returned after mobilization. Seven patients continued not to
receive analgesics after four weeks.
Conclusions: Ribavirin may have a direct antiviral property against Chikungunya leading to faster resolution of joint and soft
tissue manifestations. Key Words
: Chikungunya, lower limb arthritis, Ribavirin, observational study. J Infect Developing Countries
Received 16 August 2007 - Accepted 14 February 2008.
Copyright 2007 Ravichandran et al.
This is an open access article distributed under the Creative Commons Attribution License, which permits
unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Introduction
the effects on the patient’s mobility. The crippling
Chikungunya is a viral fever transmitted to
pain can last several months .There has been
humans by the bite of the Aedes Aegypti mosquito.
no specific treatment described for Chikungunya.
The virus belongs to the Genus Alpha virus, family
Antipyretics and analgesics form the mainstay of
Togaviridae. The disease was first described in
treatment. In those patients who continue to have
1955 by Marion Robinson and W H R Lumsden in
chronic joint pains, Chloroquine has been tried
the African subcontinent. The outbreak was in the
with some success . This observational study
year 1952 [1,2]. Since then, several cases have
was undertaken to determine the effect of the
also been reported from the Asian subcontinent
antiviral drug Ribavirin in the outcome of joint
. Recently there have been large outbreaks of
manifestations of Chikungunya. A randomized
Chikungunya in several districts of India in the last
placebo controlled trial could not be undertaken
few months . According to the World Health
since the disease disappeared from the country.
Organization (WHO), more than 1.25 million
suspected cases have been reported from India up
Materials and Methods
to October 2006 .The clinical picture of the
Ten patients who had severe arthralgia, lower
disease is high fever after a short incubation
limb swelling, pain and difficulty in walking after a
period with constitutional symptoms including
headache, photophobia, etc .Migratory arthralgia
administration of Ribavirin. Ten similar patients
of the small joints of the hand, wrist, feet and ankle
during the same period were included as controls.
are common. Rash may also appear. The fever
Those patients who recovered spontaneously
disappears in two to three days. However several
within two weeks after the febrile episode were
patients may have pain, stiffness, and swelling of
excluded from the study. All critical patients and
the joints, especially in the lower limb around the
those with systemic disease were excluded from
ankles. This leads to considerable morbidity due to
the study. Routine hematological and biochemical
– Ribavirin theraphy for Chikungunya arthritis
J Infect Developing Countries 2008; 2(2): 140-142
investigations were conducted in the beginning
even lasting for years. Brighton reported the use of
and end of the study. CRP and IgM antibodies to
Chloroquine phosphate for twenty weeks with
Chikungunya were estimated in all the patients.
significant improvement in Chikungunya arthritis.
Only patients with positive antibodies were
included in the study. All the patients were
Clinical Features and Outcomes in the
followed up for a period of four weeks. An arthritis
score was used to assess the joint involved, joint
pain, joint tenderness and swelling in a scale of
Similarly, an evaluation by the patient on a
five-point scale was also undertaken. The patients were evaluated on a weekly basis for 4 weeks and
called again after 8 weeks. In the study group all
analgesics were stopped and Ribavirin in the dose
of 200mg twice a day was given for seven days.
The female patients were screened for pregnancy
before administering the drug. The control group
continued to receive analgesics as and when required. Although the drug is well established for
other viral infections, approval of the ethics
committee of the hospital was obtained since it is a
Ribavirin is a synthetic nucleoside analogue
that inhibits a wide range of RNA and DNA
viruses. The mechanism of action of Ribavirin is
not completely defined and may be different for
In the study group out of the ten patients, five
different groups of viruses. It has been used
were males and five were females. Ages ranged
successfully in chronic Hepatitis C in association
from 27 to 74 years. Interval from the febrile
with interferon, respiratory syncytial virus, Lassa
episode was two weeks to two months. Three
fever virus, and Hantaan virus [8,9,10]. This study
patients had leucopenia. In six patients the CRP
was undertaken to determine whether antiviral
was positive. In the control group, five were males
treatment would make any difference in those
and five were females. Ages ranged from 25 to 70.
patients who continue to have arthritis even after
CRP was positive in five patients. In the study
two weeks after the febrile episode. Ribavirin was
group all patients reported improvement in pain.
chosen in view of its broad spectrum. Our
Seven patients were able walk better. In eight
patients there was reduction in joint and soft tissue
improvement in these patients. Since we had
swelling. In three patients the pain relapsed. At the
chosen patients in the subacute phase, some
end of four weeks, analgesics were discontinued in
improvement could be attributed to the natural
seven patients. Two patients complained of
history. Briolant et al.
have shown in vitro
nausea and weakness. No other side effects were
combination of interferon alfa 2B and Ribavirin has
seen. Three patients were restarted on analgesics.
a synergestic antiviral effect against Chikungunya
The results of both groups are shown in the
Our study has several limitations: a) it involves
only a small number of patients; b) it was not a
planned study where the patients could be
Although Chikungunya is a self-limiting viral
distributed randomly and compared with a group
disease with hardly any mortality, a considerable
receiving placebo. This was not possible since the
number of patients continue to have crippling joint
disease rapidly disappeared from the country.
pain in the lower limbs which affects their mobility.
However, our observations may assist other
These patients continue to take analgesics for long
centers in the world undertaking clinical trials of
periods of time with possible complications. The
joint manifestations could also become chronic,
– Ribavirin theraphy for Chikungunya arthritis
J Infect Developing Countries 2008; 2(2): 140-142
chronic hepatitis C; New Eng J Med,339 (21),1485-
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: Rajan Ravichandran, Director,
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Madras Institute of Nephrology, Tel: 91 44 24833340,
arthropathy:a clinical description J Rheumotol 1980;(2):
Fax: 91 44 23723244, Email: [email protected]
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Conflict of interest:
No conflict of interest is declared.
chronic Chikungunya arthritis. An open pilot study. S Afr
8. McHutchison JG et al
. (1998) Interferon alfa 2-b alone or
in combination with ribavirin as initial treatment for
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