Reumatismo inflamatorio crónico post-chikungunya: fisiopatología, manifestaciones clínicas y manejo basado en evidencia
Palabras clave:
virus chikungunya, artritis postinfecciosa, fármaco antirreumático modificador de la enfermedad, artritis reumatoide
Resumen
Introducción: el reumatismo inflamatorio crónico post-chikungunya (pCHIK-CIR) afecta al 25–65% de los individuos infectados con el virus chikungunya (CHIKV), representando una carga sustancial para la salud global. La condición imita a la artritis reumatoide clínica e inmunológicamente, sin embargo carece de criterios diagnósticos estandarizados y protocolos de tratamiento basados en evidencia.
Objetivos: sintetizar la evidencia actual sobre la fisiopatología, factores de riesgo, manifestaciones clínicas, diagnóstico diferencial y estrategias terapéuticas para pCHIK-CIR, con énfasis en avances recientes en la comprensión de mecanismos inmunes y enfoques de tratamiento.
Métodos: revisión integral de la literatura revisada por pares en bases de datos principales (PubMed, Scopus, Web of Science) enfocada en estudios publicados entre 2015–2026, priorizando revisiones sistemáticas, ensayos clínicos aleatorizados, estudios de cohortes y guías internacionales.
Resultados: el pCHIK-CIR se desarrolla a través de interacciones complejas entre persistencia viral, autoinmunidad y desregulación sostenida de citocinas, particularmente involucrando IL-6, IL-1β, TNF-α y CXCL8. El sexo femenino (riesgo relativo 1,5–4,0), edad >35 años, poliartralgia aguda severa y síntomas persistentes al día 21° predicen cronicidad. La condición se presenta como poliartritis simétrica que afecta pequeñas articulaciones, muñecas y tobillos, demostrando con ultrasonido sinovitis en >90% de los casos crónicos. El metotrexato muestra la evidencia más fuerte de eficacia (reducción media DAS28 2,67 IC 95% 1,84–3,49), con datos emergentes que apoyan DMARDs en combinación y biológicos dirigidos. Dos vacunas (IXCHIQ y Vimkunya) recibieron aprobación regulatoria en 2023–2025, demostrando tasas de seroprotección >96%.
Conclusiones: el pCHIK-CIR representa una artropatía inflamatoria post-infecciosa distinta que requiere reconocimiento temprano y manejo reumatológico. La evidencia apoya el metotrexato como terapia de primera línea para enfermedad moderada a severa, con corticosteroides para exacerbaciones agudas. La investigación futura debe enfocarse en estratificación de pacientes basada en biomarcadores, medidas de resultado estandarizadas y seguridad a largo plazo de terapias inmunomoduladoras.
Citas
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2. Ribeiro Dos Santos G, Jawed F, Mukandavire Ch, Deol A, Scarponi D, Mboera LEG, et al. Global burden of chikungunya virus infections and the potential benefit of vaccination campaigns. Nat Med [Internet]. 2025 [cited 2025 Nov 15];31(7):2342-9. Available from: https://pubmed.ncbi.nlm.nih.gov/40495015/
3. Burt FJ, Chen W, Miner JJ, Lenschow DJ, Merits A, Schnettler E, et al. Chikungunya virus: an update on the biology and pathogenesis of this emerging pathogen. Lancet Infect Dis [Internet]. 2017 [cited 2024 Jun 10];17(4):e107-e117. Available from: https://pubmed.ncbi.nlm.nih.gov/28159534/
4. Staples JE, Hills SL, Powers AM. Chikungunya. [Internet]. In: CDC Yellow Book: Health Information for International Travel. New York: Oxford University Press; 2026. [cited 2026 Apr 8]. Available from: https://www.cdc.gov/yellow-book/hcp/travel-associated-infections-diseases/chikungunya.html
5. Cortes-Azuero O, O'Driscoll M, Ribeiro Dos Santos G, de Jesus R, de Lima STS, Scarponi D, et al. The epidemiology of chikungunya virus in Brazil and the potential impact of vaccines: a mathematical modelling study. Lancet Infect Dis [Internet]. 2026 [cited 2026 May 6];26(4):406-16. Available from: https://pubmed.ncbi.nlm.nih.gov/41319657/
6. Dos Santos Lázari C, Severo Ramundo M, Ten-Caten F, Bressan CS, Bispo de Filippis AM, Manuli ER, et al. Clinical markers of post-Chikungunya chronic inflammatory joint disease: A Brazilian cohort. PLoS Negl Trop Dis [Internet]. 2023 [cited 2024 Jun 10];17(1):e0011037. Available from: https://pubmed.ncbi.nlm.nih.gov/36608155/
7. Kang H, Auzenbergs M, Clapham H, Maure C, Kim JH, Salje H, et al. Chikungunya seroprevalence, force of infection, and prevalence of chronic disability after infection in endemic and epidemic settings: a systematic review, meta-analysis, and modelling study. Lancet Infect Dis [Internet]. 2024 [cited 2025 Feb 4];24(5):488-503. Available from: https://pubmed.ncbi.nlm.nih.gov/38342105/
8. Guillot X, Ribera A, Gasque P. Chikungunya-Induced arthritis in Reunion Island: A Long-term observational follow-up study showing frequently persistent joint symptoms, some cases of persistent chikungunya immunoglobulin m positivity, and no anticyclic citrullinated peptide seroconversion after 13 years. J Infect Dis [Internet]. 2020 [cited 2024 Jun 10];222(10):1740-44. Available from: https://pubmed.ncbi.nlm.nih.gov/32428203/
9. Amaral JK, Bilsborrow JB, Schoen RT. Chronic chikungunya arthritis and rheumatoid arthritis: What they have in common. Am J Med [Internet]. 2020 [cited 2024 Jun 10];133(3):e91-e97. Available from: https://pubmed.ncbi.nlm.nih.gov/31705850/
10. Miner JJ, Aw-Yeang HX, Fox JM, Taffner S, Malkova ON, Oh ST, et al. Chikungunya viral arthritis in the United States: a mimic of seronegative rheumatoid arthritis. Arthritis Rheumatol [Internet]. 2015 [cited 2024 Jun 10];67(5):1214-20. Available from: https://pubmed.ncbi.nlm.nih.gov/25605621/
11. Severo Ramundo M, Cordenonsi da Fonseca G, Ten-Caten F, Gerber AL, Guimarães AP, Manuli ER, et al. Transcriptomic insights into early mechanisms underlying post-chikungunya chronic inflammatory joint disease. Sci Rep [Internet]. 2025 [cited 2025 Novb 10];15(1):6745. Available from: https://pubmed.ncbi.nlm.nih.gov/40000671/
12. Conforti A, Lavalle G, Varini F, Lucchetti L, Cataldi G, Faticoni A, et al. Pro-Inflammatory cytokines as early predictors of chronic rheumatologic disease following chikungunya virus infection. J Clin Med [Internet]. 2025 [cited 2025 Nov 10];14(19):6720. Available from: https://pubmed.ncbi.nlm.nih.gov/41095803/
13. Jacob-Nascimento LC, Carvalho CX, Oliveira Silva MM, Kikuti M, Oliveira Anjos R, Rodrigues Barbosa Fradico J, et al. Acute-Phase levels of CXCL8 as risk factor for chronic arthralgia following chikungunya virus infection. Front Immunol [Internet]. 2021 [cited 2024 Jun 10]; 12:744183. Available from: https://pubmed.ncbi.nlm.nih.gov/34659240/
14. Manimunda SP, Vijayachari P, Uppoor R, Sugunan AP, Singh SS, Rai SK, et al. Clinical progression of chikungunya fever during acute and chronic arthritic stages and the changes in joint morphology as revealed by imaging. Trans R Soc Trop Med Hyg [Internet]. 2010 [cited 2024 Jun 10];104(6):392-9. Available from: https://pubmed.ncbi.nlm.nih.gov/20171708/ Subscription required
15. Webb E, Michelen M, Rigby I, Dagens A, Dahmash D, Cheng V, et al. An evaluation of global Chikungunya clinical management guidelines: A systematic review. EClinicalMedicine [Internet]. 2022 [cited 2024 Jun 10]; 54:101672. Available from: https://www.sciencedirect.com/science/article/pii/S2589537022004023
16. Watson H, Del Valle-Mendoza J, Aguilar-Luis MA, Aquino-Ortega R, Silva-Caso W, Tarazona-Castro Y, et al. Global ultrasound synovitis scores reflect symptom severity and patient outcomes in chronic chikungunya disease. Rheumatology (Oxford) [Internet]. 2025 [cited 2026 Feb 10];64(6):3352-60. Available from: https://pubmed.ncbi.nlm.nih.gov/39928357/
17. Benjamanukul S, Osiri M, Chansaenroj J, Chirathaworn Ch, Poovorawan Y. Rheumatic manifestations of Chikungunya virus infection: Prevalence, patterns, and enthesitis. PLoS One [Internet]. 2021 [cited 2024 Jun 10];16(4): e0249867. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC8062098/
18. Leidersnaider CL, Sztajnbok FR, Silva Freire Coutinho E, Pereira Vaz JL, Porangaba M, Hamdan PC, et al. Chikungunya fever: Comparison study of synovitis and tenosynovitis of the hands and wrists using physical examination, ultrasound, and MRI findings. J Ultrasound Med [Internet]. 2022 [cited 2024 Jun 10];41(4):865-73. Available from: https://pubmed.ncbi.nlm.nih.gov/34170018/
19. Blettery M, Brunier L, Polomat K, Moinet F, Deligny Ch, Arfi S, et al. Brief report: Management of chronic post-chikungunya rheumatic disease: The Martinican experience. Arthritis Rheumatol [Internet]. 2016 [cited 2024 Jun 10];68(11):2817-24. Available from: https://pubmed.ncbi.nlm.nih.gov/27273928/ Subscription required
20. Mariz CA, Menezes N de Oliveira N, Alexandre SCA, Viana I, de Morais CNL, Marques ETA, et al. Symptomatic chikungunya and chronic post-infection arthralgia in a highly endemic setting in Northeastern Brazil, 2018-2019: Clinical characteristics, prevalence and associated factors. PLoS One [Internet]. 2026 [cited 2026 Apr 8];21(1):e0328141. Available from: https://pubmed.ncbi.nlm.nih.gov/41529049/
21. Huits R, De Kort J, Van Den Berg R, Chong L, Tsoumanis A, Eggermont K, et al. Chikungunya virus infection in Aruba: Diagnosis, clinical features and predictors of post-chikungunya chronic polyarthralgia. PLoS One [Internet]. 2018 [cited 2024 Jun 10];13(4):e0196630. Available from: https://pubmed.ncbi.nlm.nih.gov/29709007/
22. Amaral JK, Bingham CO, Taylor PC, Vilá LM, Weinblatt ME, Schoen RT. Therapy for chikungunya arthritis: A study of 133 brazilian patients. Am J Trop Med Hyg [Internet]. 2023 [cited 2024 Jun 10];109(3):542-7. Available from: https://pubmed.ncbi.nlm.nih.gov/37549898/
23. Watson H, Nogueira-Hayd RL, Rodrigues-Moreno M, Naveca F, Calusi G, Suchowiecki K, et al. Tender and swollen joint counts are poorly associated with disability in chikungunya arthritis compared to rheumatoid arthritis. Sci Rep [Internet]. 2021 [cited 2024 Jun 10] ;11(1):18578. Available from: https://pubmed.ncbi.nlm.nih.gov/34535727/
24. Runowska M, Majewski D, Niklas K, Puszczewicz M. Chikungunya virus: a rheumatologist's perspective. Clin Exp Rheumatol [Internet]. 2018 [cited 2024 Jun 10];36(3):494-501. Available from: https://pubmed.ncbi.nlm.nih.gov/29533749/
25. Ellis G, Decker CF. Chikungunya vaccine. Dis Mon. 2026 Apr 15:102129. doi: 10.1016/j.disamonth.2026.102129 Available from: https://pubmed.ncbi.nlm.nih.gov/41991419/
26. Amaral JK, Sutaria R, Schoen RT. Treatment of chronic chikungunya arthritis with Methotrexate: A systematic review. Arthritis Care Res (Hoboken) [Internet]. 2018 [cited 2024 Jun 10];70(10):1501-8. Available from: https://pubmed.ncbi.nlm.nih.gov/29361202/
27. Amaral JK, Schoen RT, Bingham CO, Chang A, Cândido EL. Immunomodulatory therapy of chikungunya arthritis: systematic review and meta-analysis. J Travel Med [Internet]. 2025 [cited 2026 Apr 8];32(6): taaf067. Available from: https://pubmed.ncbi.nlm.nih.gov/40657814/ Subscription required
28. Amaral JK, Taylor PC, Teixeira MM, Morrison TET, Schoen RT. The clinical features, pathogenesis and methotrexate therapy of chronic chikungunya arthritis. Viruses [Internet]. 2019 [cited 2024 Jun 10];11(3):289. Available from: https://pubmed.ncbi.nlm.nih.gov/30909365/
29. Alvarado LI, Lorenzi OD, Torres-Velásquez BC, Sharp TM, Vargas L, Muñoz-Jordán JL, et al. Distinguishing patients with laboratory-confirmed chikungunya from dengue and other acute febrile illnesses, Puerto Rico, 2012-2015. PLoS Negl Trop Dis [Internet]. 2019 [cited 2024 Jun 10];13(7): e0007562. Available from: https://pubmed.ncbi.nlm.nih.gov/31329598/
30. Miner JJ, Cook LE, Hong JP, Smith AM, Richner JM, Shimak RM, et al. Therapy with CTLA4-Ig and an antiviral monoclonal antibody controls chikungunya virus arthritis. Sci Transl Med [Internet]. 2017 [cited 2024 Jun 10];9(375):eaah3438. Available from: https://pubmed.ncbi.nlm.nih.gov/28148840/
31. Kling K, Falman A, Branke L, Ramharter M, Rothe C, Schönfeld Ch, et al. Vaccination against chikungunya - a systematic review on the immunogenicity, tolerability, and safety of the live-attenuated vaccine (LAV) Ixchiq and the virus like particle (VLP) vaccine Vimkunya. Vaccine [Internet]. 2026 [cited 2026 Apr 8]; 75:128251. Available from: https://pubmed.ncbi.nlm.nih.gov/41564838/
32. Buerger V, Maurer G, Kosulin K, Hochreiter R, Larcher-Senn J, Dubischar K, Eder-Lingelbach S. Combined immunogenicity evaluation for a new single-dose live-attenuated chikungunya vaccine. J Travel Med [Internet]. 2024 [cited 2025 Mar 6];31(7): taae084. Available from: https://pubmed.ncbi.nlm.nih.gov/38959854/
33. Buerger V, Pfeiffer A, Schoengrundner P, Seebacher J, Hochreiter R, Kosulin K, et al. Safety and immunogenicity of a live-attenuated chikungunya virus vaccine in adolescents: final results from a 12-month, double-blind, randomised, placebo-controlled, phase 3 trial in endemic areas of Brazil. Lancet Infect Dis [Internet]. 2026 [cited 2026 Apr 8];26(4):417-28. Available from: https://pubmed.ncbi.nlm.nih.gov/41380703/ Subscription required
34. Richardson JS, Anderson DM, Mendy J, Tindale LC, Muhammad S, Loreth T, et al. Chikungunya virus virus-like particle vaccine safety and immunogenicity in adolescents and adults in the USA: a phase 3, randomised, double-blind, placebo-controlled trial. Lancet [Internet]. 2025 [cited 2025 Nov 8];405(10487):1343-52. Available from: https://pubmed.ncbi.nlm.nih.gov/40158526/
35. Vondeling GT, Croda J, Jelinek T, Kassianos G, Kollaritsch H, Luong Nguyen LB, et al. Post-marketing safety evaluation of the live-attenuated chikungunya vaccine (IXCHIQ). Vaccine [Internet]. 2026 [cited 2026 Apr 8]; 79:128491. Available from: https://www.sciencedirect.com/science/article/pii/S0264410X26002999
36. Tindale LC, Richardson JS, Anderson DM, Mendy J, Muhammad S, Loreth T, et al. Chikungunya virus virus-like particle vaccine safety and immunogenicity in adults older than 65 years: a phase 3, randomised, double-blind, placebo-controlled trial. Lancet [Internet]. 2025 [cited 2025 Nov 8];405(10487):1353-61. Available from: https://pubmed.ncbi.nlm.nih.gov/40158524/ Subscription required
2. Ribeiro Dos Santos G, Jawed F, Mukandavire Ch, Deol A, Scarponi D, Mboera LEG, et al. Global burden of chikungunya virus infections and the potential benefit of vaccination campaigns. Nat Med [Internet]. 2025 [cited 2025 Nov 15];31(7):2342-9. Available from: https://pubmed.ncbi.nlm.nih.gov/40495015/
3. Burt FJ, Chen W, Miner JJ, Lenschow DJ, Merits A, Schnettler E, et al. Chikungunya virus: an update on the biology and pathogenesis of this emerging pathogen. Lancet Infect Dis [Internet]. 2017 [cited 2024 Jun 10];17(4):e107-e117. Available from: https://pubmed.ncbi.nlm.nih.gov/28159534/
4. Staples JE, Hills SL, Powers AM. Chikungunya. [Internet]. In: CDC Yellow Book: Health Information for International Travel. New York: Oxford University Press; 2026. [cited 2026 Apr 8]. Available from: https://www.cdc.gov/yellow-book/hcp/travel-associated-infections-diseases/chikungunya.html
5. Cortes-Azuero O, O'Driscoll M, Ribeiro Dos Santos G, de Jesus R, de Lima STS, Scarponi D, et al. The epidemiology of chikungunya virus in Brazil and the potential impact of vaccines: a mathematical modelling study. Lancet Infect Dis [Internet]. 2026 [cited 2026 May 6];26(4):406-16. Available from: https://pubmed.ncbi.nlm.nih.gov/41319657/
6. Dos Santos Lázari C, Severo Ramundo M, Ten-Caten F, Bressan CS, Bispo de Filippis AM, Manuli ER, et al. Clinical markers of post-Chikungunya chronic inflammatory joint disease: A Brazilian cohort. PLoS Negl Trop Dis [Internet]. 2023 [cited 2024 Jun 10];17(1):e0011037. Available from: https://pubmed.ncbi.nlm.nih.gov/36608155/
7. Kang H, Auzenbergs M, Clapham H, Maure C, Kim JH, Salje H, et al. Chikungunya seroprevalence, force of infection, and prevalence of chronic disability after infection in endemic and epidemic settings: a systematic review, meta-analysis, and modelling study. Lancet Infect Dis [Internet]. 2024 [cited 2025 Feb 4];24(5):488-503. Available from: https://pubmed.ncbi.nlm.nih.gov/38342105/
8. Guillot X, Ribera A, Gasque P. Chikungunya-Induced arthritis in Reunion Island: A Long-term observational follow-up study showing frequently persistent joint symptoms, some cases of persistent chikungunya immunoglobulin m positivity, and no anticyclic citrullinated peptide seroconversion after 13 years. J Infect Dis [Internet]. 2020 [cited 2024 Jun 10];222(10):1740-44. Available from: https://pubmed.ncbi.nlm.nih.gov/32428203/
9. Amaral JK, Bilsborrow JB, Schoen RT. Chronic chikungunya arthritis and rheumatoid arthritis: What they have in common. Am J Med [Internet]. 2020 [cited 2024 Jun 10];133(3):e91-e97. Available from: https://pubmed.ncbi.nlm.nih.gov/31705850/
10. Miner JJ, Aw-Yeang HX, Fox JM, Taffner S, Malkova ON, Oh ST, et al. Chikungunya viral arthritis in the United States: a mimic of seronegative rheumatoid arthritis. Arthritis Rheumatol [Internet]. 2015 [cited 2024 Jun 10];67(5):1214-20. Available from: https://pubmed.ncbi.nlm.nih.gov/25605621/
11. Severo Ramundo M, Cordenonsi da Fonseca G, Ten-Caten F, Gerber AL, Guimarães AP, Manuli ER, et al. Transcriptomic insights into early mechanisms underlying post-chikungunya chronic inflammatory joint disease. Sci Rep [Internet]. 2025 [cited 2025 Novb 10];15(1):6745. Available from: https://pubmed.ncbi.nlm.nih.gov/40000671/
12. Conforti A, Lavalle G, Varini F, Lucchetti L, Cataldi G, Faticoni A, et al. Pro-Inflammatory cytokines as early predictors of chronic rheumatologic disease following chikungunya virus infection. J Clin Med [Internet]. 2025 [cited 2025 Nov 10];14(19):6720. Available from: https://pubmed.ncbi.nlm.nih.gov/41095803/
13. Jacob-Nascimento LC, Carvalho CX, Oliveira Silva MM, Kikuti M, Oliveira Anjos R, Rodrigues Barbosa Fradico J, et al. Acute-Phase levels of CXCL8 as risk factor for chronic arthralgia following chikungunya virus infection. Front Immunol [Internet]. 2021 [cited 2024 Jun 10]; 12:744183. Available from: https://pubmed.ncbi.nlm.nih.gov/34659240/
14. Manimunda SP, Vijayachari P, Uppoor R, Sugunan AP, Singh SS, Rai SK, et al. Clinical progression of chikungunya fever during acute and chronic arthritic stages and the changes in joint morphology as revealed by imaging. Trans R Soc Trop Med Hyg [Internet]. 2010 [cited 2024 Jun 10];104(6):392-9. Available from: https://pubmed.ncbi.nlm.nih.gov/20171708/ Subscription required
15. Webb E, Michelen M, Rigby I, Dagens A, Dahmash D, Cheng V, et al. An evaluation of global Chikungunya clinical management guidelines: A systematic review. EClinicalMedicine [Internet]. 2022 [cited 2024 Jun 10]; 54:101672. Available from: https://www.sciencedirect.com/science/article/pii/S2589537022004023
16. Watson H, Del Valle-Mendoza J, Aguilar-Luis MA, Aquino-Ortega R, Silva-Caso W, Tarazona-Castro Y, et al. Global ultrasound synovitis scores reflect symptom severity and patient outcomes in chronic chikungunya disease. Rheumatology (Oxford) [Internet]. 2025 [cited 2026 Feb 10];64(6):3352-60. Available from: https://pubmed.ncbi.nlm.nih.gov/39928357/
17. Benjamanukul S, Osiri M, Chansaenroj J, Chirathaworn Ch, Poovorawan Y. Rheumatic manifestations of Chikungunya virus infection: Prevalence, patterns, and enthesitis. PLoS One [Internet]. 2021 [cited 2024 Jun 10];16(4): e0249867. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC8062098/
18. Leidersnaider CL, Sztajnbok FR, Silva Freire Coutinho E, Pereira Vaz JL, Porangaba M, Hamdan PC, et al. Chikungunya fever: Comparison study of synovitis and tenosynovitis of the hands and wrists using physical examination, ultrasound, and MRI findings. J Ultrasound Med [Internet]. 2022 [cited 2024 Jun 10];41(4):865-73. Available from: https://pubmed.ncbi.nlm.nih.gov/34170018/
19. Blettery M, Brunier L, Polomat K, Moinet F, Deligny Ch, Arfi S, et al. Brief report: Management of chronic post-chikungunya rheumatic disease: The Martinican experience. Arthritis Rheumatol [Internet]. 2016 [cited 2024 Jun 10];68(11):2817-24. Available from: https://pubmed.ncbi.nlm.nih.gov/27273928/ Subscription required
20. Mariz CA, Menezes N de Oliveira N, Alexandre SCA, Viana I, de Morais CNL, Marques ETA, et al. Symptomatic chikungunya and chronic post-infection arthralgia in a highly endemic setting in Northeastern Brazil, 2018-2019: Clinical characteristics, prevalence and associated factors. PLoS One [Internet]. 2026 [cited 2026 Apr 8];21(1):e0328141. Available from: https://pubmed.ncbi.nlm.nih.gov/41529049/
21. Huits R, De Kort J, Van Den Berg R, Chong L, Tsoumanis A, Eggermont K, et al. Chikungunya virus infection in Aruba: Diagnosis, clinical features and predictors of post-chikungunya chronic polyarthralgia. PLoS One [Internet]. 2018 [cited 2024 Jun 10];13(4):e0196630. Available from: https://pubmed.ncbi.nlm.nih.gov/29709007/
22. Amaral JK, Bingham CO, Taylor PC, Vilá LM, Weinblatt ME, Schoen RT. Therapy for chikungunya arthritis: A study of 133 brazilian patients. Am J Trop Med Hyg [Internet]. 2023 [cited 2024 Jun 10];109(3):542-7. Available from: https://pubmed.ncbi.nlm.nih.gov/37549898/
23. Watson H, Nogueira-Hayd RL, Rodrigues-Moreno M, Naveca F, Calusi G, Suchowiecki K, et al. Tender and swollen joint counts are poorly associated with disability in chikungunya arthritis compared to rheumatoid arthritis. Sci Rep [Internet]. 2021 [cited 2024 Jun 10] ;11(1):18578. Available from: https://pubmed.ncbi.nlm.nih.gov/34535727/
24. Runowska M, Majewski D, Niklas K, Puszczewicz M. Chikungunya virus: a rheumatologist's perspective. Clin Exp Rheumatol [Internet]. 2018 [cited 2024 Jun 10];36(3):494-501. Available from: https://pubmed.ncbi.nlm.nih.gov/29533749/
25. Ellis G, Decker CF. Chikungunya vaccine. Dis Mon. 2026 Apr 15:102129. doi: 10.1016/j.disamonth.2026.102129 Available from: https://pubmed.ncbi.nlm.nih.gov/41991419/
26. Amaral JK, Sutaria R, Schoen RT. Treatment of chronic chikungunya arthritis with Methotrexate: A systematic review. Arthritis Care Res (Hoboken) [Internet]. 2018 [cited 2024 Jun 10];70(10):1501-8. Available from: https://pubmed.ncbi.nlm.nih.gov/29361202/
27. Amaral JK, Schoen RT, Bingham CO, Chang A, Cândido EL. Immunomodulatory therapy of chikungunya arthritis: systematic review and meta-analysis. J Travel Med [Internet]. 2025 [cited 2026 Apr 8];32(6): taaf067. Available from: https://pubmed.ncbi.nlm.nih.gov/40657814/ Subscription required
28. Amaral JK, Taylor PC, Teixeira MM, Morrison TET, Schoen RT. The clinical features, pathogenesis and methotrexate therapy of chronic chikungunya arthritis. Viruses [Internet]. 2019 [cited 2024 Jun 10];11(3):289. Available from: https://pubmed.ncbi.nlm.nih.gov/30909365/
29. Alvarado LI, Lorenzi OD, Torres-Velásquez BC, Sharp TM, Vargas L, Muñoz-Jordán JL, et al. Distinguishing patients with laboratory-confirmed chikungunya from dengue and other acute febrile illnesses, Puerto Rico, 2012-2015. PLoS Negl Trop Dis [Internet]. 2019 [cited 2024 Jun 10];13(7): e0007562. Available from: https://pubmed.ncbi.nlm.nih.gov/31329598/
30. Miner JJ, Cook LE, Hong JP, Smith AM, Richner JM, Shimak RM, et al. Therapy with CTLA4-Ig and an antiviral monoclonal antibody controls chikungunya virus arthritis. Sci Transl Med [Internet]. 2017 [cited 2024 Jun 10];9(375):eaah3438. Available from: https://pubmed.ncbi.nlm.nih.gov/28148840/
31. Kling K, Falman A, Branke L, Ramharter M, Rothe C, Schönfeld Ch, et al. Vaccination against chikungunya - a systematic review on the immunogenicity, tolerability, and safety of the live-attenuated vaccine (LAV) Ixchiq and the virus like particle (VLP) vaccine Vimkunya. Vaccine [Internet]. 2026 [cited 2026 Apr 8]; 75:128251. Available from: https://pubmed.ncbi.nlm.nih.gov/41564838/
32. Buerger V, Maurer G, Kosulin K, Hochreiter R, Larcher-Senn J, Dubischar K, Eder-Lingelbach S. Combined immunogenicity evaluation for a new single-dose live-attenuated chikungunya vaccine. J Travel Med [Internet]. 2024 [cited 2025 Mar 6];31(7): taae084. Available from: https://pubmed.ncbi.nlm.nih.gov/38959854/
33. Buerger V, Pfeiffer A, Schoengrundner P, Seebacher J, Hochreiter R, Kosulin K, et al. Safety and immunogenicity of a live-attenuated chikungunya virus vaccine in adolescents: final results from a 12-month, double-blind, randomised, placebo-controlled, phase 3 trial in endemic areas of Brazil. Lancet Infect Dis [Internet]. 2026 [cited 2026 Apr 8];26(4):417-28. Available from: https://pubmed.ncbi.nlm.nih.gov/41380703/ Subscription required
34. Richardson JS, Anderson DM, Mendy J, Tindale LC, Muhammad S, Loreth T, et al. Chikungunya virus virus-like particle vaccine safety and immunogenicity in adolescents and adults in the USA: a phase 3, randomised, double-blind, placebo-controlled trial. Lancet [Internet]. 2025 [cited 2025 Nov 8];405(10487):1343-52. Available from: https://pubmed.ncbi.nlm.nih.gov/40158526/
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