title: Purpuric macules with vesiculobullous lesions: a novel manifestation of Chikungunya.
abstract: BACKGROUND
  Chikungunya (CHIK) is an emerging viral disease with a myriad of cutaneous manifestations.
  
  
  OBJECTIVE
  The aim of our study was to document the morphology and evolution of skin lesions in cases presenting with fever, purpuric macules and vesiculobullous lesions, to confirm its causative relationship with CHIK, and to investigate further in order to delineate possible mechanisms of bulla formation in these cases.
  
  
  METHODS
  A prospective, descriptive hospital-based study was carried out at a tertiary health care centre in Kerala. A total of 10 patients were enrolled in the study and investigated.
  
  
  RESULTS
  All cases had morbilliform eruption prior to onset of purpuric macules. Eight cases developed vesiculobullous lesions that arose either de novo or over a part or whole of the purpuric macules. Skin lesions resolved within an average of 7.6 days leaving post-inflammatory hypopigmentation. IgM CHIK enzyme-linked immunosorbent assay (ELISA) was positive in all 10 patients. Tzanck smear from the bullae showed lymphocytes in most cases along with acantholytic cells, necrotic keratinocytes or occasional neutrophils. Skin biopsy showed intraepidermal or subepidermal bullae. Immunohistochemistry revealed predominantly CD8 positive T lymphocytes in the infiltrate. The prognosis was good with supportive management alone.
  
  
  CONCLUSIONS
  The clinical features in our cases are comparable to the 3 previous reports of vesiculobullous lesions in CHIK affected infants. Based on the current evidence, we hypothesize that at least 2 mechanisms are at play for these skin lesions; CHIK virus induced keratinocyte necrosis followed by a cytotoxic immune response, and possible modulation of rash by drugs.
  
  
  CONCLUSIONS
  With severe epidemics of CHIK spreading from Asia and Africa to the Western hemisphere, we must consider bullous CHIK as a differential diagnosis in cases with fever and purpuric and vesiculobullous lesions.
authors.affiliation: Department of Dermatology, Calicut Medical College, Calicut, Kerala, India. jaheershanijas@gmail.com
authors.forename: Jaheersha
authors.initials: J
authors.lastname: Pakran
authors.forename: Mamatha
authors.initials: M
authors.lastname: George
authors.forename: Najeeba
authors.initials: N
authors.lastname: Riyaz
authors.forename: Riyaz
authors.initials: R
authors.lastname: Arakkal
authors.forename: Sandhya
authors.initials: S
authors.lastname: George
authors.forename: Uma
authors.initials: U
authors.lastname: Rajan
authors.forename: Anza
authors.initials: A
authors.lastname: Khader
authors.forename: Sumi
authors.initials: S
authors.lastname: Thomas
authors.forename: Rahima
authors.initials: R
authors.lastname: Abdurahman
authors.forename: Saritha
authors.initials: S
authors.lastname: Sasidharanpillai
authors.forename: Lekha
authors.initials: L
authors.lastname: Thumbayil
mesh_terms: D000051:Acantholysis / Q000276:immunology / Q000473:pathology / Q000821:virology; D018354:Alphavirus Infections / Q000150:complications / Q000276:immunology / Q000473:pathology; D000914:Antibodies, Viral / Q000276:immunology; D001706:Biopsy; D001768:Blister / Q000276:immunology / Q000473:pathology / Q000821:virology*; D018414:CD8-Positive T-Lymphocytes / Q000276:immunology / Q000473:pathology / Q000821:virology; D065632:Chikungunya Fever; D002648:Child; D005260:Female; D005334:Fever / Q000276:immunology / Q000821:virology; D006801:Humans; D017496:Hypopigmentation / Q000276:immunology / Q000473:pathology / Q000821:virology; D007194:India; D007223:Infant; D015603:Keratinocytes / Q000276:immunology / Q000473:pathology / Q000821:virology; D008297:Male; D008875:Middle Aged; D009504:Neutrophils / Q000276:immunology / Q000473:pathology / Q000821:virology; D011379:Prognosis; D011693:Purpura / Q000276:immunology / Q000473:pathology* / Q000821:virology*; D012867:Skin / Q000276:immunology / Q000473:pathology / Q000821:virology; D012872:Skin Diseases, Vesiculobullous / Q000276:immunology / Q000473:pathology* / Q000821:virology*
chemical_list: D000914:Antibodies, Viral