{'fraction_non_alphanumeric': 0.029813318473112287, 'fraction_numerical': 0.010030649205906938, 'mean_word_length': 5.93050193050193, 'pattern_counts': {'":': 0, '<': 0, '<?xml version=': 0, '>': 0, 'https://': 0, 'lorem ipsum': 0, 'www.': 0, 'xml': 0}, 'pii_count': 0, 'substrings_counts': 0, 'word_list_counts': {'cursed_substrings.json': 0, 'profanity_word_list.json': 0, 'sexual_word_list.json': 0, 'zh_pornsignals.json': 0}}
Chikungunya Fever With Seizures, Myocarditis, and Severe Thrombocytopenia in a Child With Osteosarcoma

To the Editor: Children undergoing treatment for cancer in tropical countries are vulnerable to endemic and epidemic infections such as malaria, dengue, and chikungunya.[1,2] Infectious complications such as cytopenias, seizures, musculoskeletal symptoms, and organ dysfunction often mimic and overlap with manifestations of the primary malignancy and/or chemotherapy-related toxicity. We describe a child with osteosarcoma who developed complicated chikungunya fever during chemotherapy. A 12-year-old female diagnosed with osteosarcoma of the right femur was started on neoadjuvant chemotherapy comprising ifosfamide, adriamycin, and cisplatin. Ten days post-sixth cycle, she developed biphasic fever associated with severe myalgias and nonbilious vomiting. The hemogram revealed neutrophilic leukocytosis and thrombocytopenia (platelet count of 20,000/μl). There was exquisitely tender swelling of right knee and ankle joint, and erythematous maculopapular rash on lower limbs. The clinical course was further complicated by generalized seizures, respiratory distress, and hypotensive shock. Echocardiography revealed global hypokinesia and an ejection fraction of 36%. Dengue serology, smears for malarial parasite, serology for scrub typhus, antinuclear antibody (for systemic lupus erythematosus), and antistreptolysin O titer (for rheumatic fever) were negative. IgM capture enzyme-linked immunosorbent assay (IgM-ELISA) for chikungunya was positive. Anthracycline-induced cardiotoxicity, sepsis-induced cardiomyopathy, and viralmyocarditis were considered as probable causes for the cardiac failure. Childwas treatedwith broad-spectrumantibiotics,morphine infusion for analgesia, inotropic support (dobutamine and noradrenaline), and platelet transfusions. Thiamine was also administered as a correctable cause of cardiomyopathy, since the child was malnourished. Fever resolved after 2 weeks. Enalapril was added after stabilization of blood pressure to decrease cardiac afterload. Cardiac function and platelet count gradually recovered over 3 weeks and she was successfully operated after 1 month of recovery from the febrile illness. Chikungunya is usually self-limiting and rarely complicated.[3] It can result in a gamut of neurological manifestations including seizures.[4] Severe, disabling arthralgia/arthritis akin to what was seen in the index case is a hallmark of chikungunya.[5] Mild to moderate thrombocytopenia is reported in more than one-third of patients, though our child had severe thrombocytopenia.[6] Cardiac complications are rarely reported in chikungunya. Interestingly, a large proportion of reported patients with cardiac failure or arrhythmias in the acute phase of chikungunya had underlying heart disease.[4,7] Although our child had no evidence of heart disease at start of treatment of osteosarcoma, she received 300 mg/m2 of doxorubicin as part of chemotherapy. After 300–450 mg/m2 of cumulative exposure to doxorubicin, 25% of patients greater than 15 years of age can experience systolic dysfunction.[8] The clinical profile and IgM-ELISA were highly suggestive of the diagnosis of chikungunya. However, definitive diagnosis by viral PCRor isolation in culture was not performed as these investigations were unavailable at our center. This case report re-emphasizes the importance of investigation andmanagement of tropical infections in cancer patients in tropical countries. Timely diagnosis and treatment can result in excellent outcomes.