In this case, the history of recent traveling to the Caribbean and the abrupt onset fever with arthralgias and maculopapular rash serves to suggest certain diagnostic possibilities: Malaria, Chikungunya, Dengue and/or Leptospirosis. Thrombocytopenia and leucopenia are also suggestive of a viral process. The main laboratory finding in Chikungunya infection is lymphopenia, and is associated with viremia when the lymphocyte count is less than 1000 per cubic millimeter. Elevation of liver function tests are also reported, with SGOT and SGPT values elevated up to 1.5 times de normal level in up to 50 % of cases [1–8].

From the clinical point of view the presence of symmetrical arthritis, fever and a maculopapular rash in this patient are strongly suggestive of Chikungunya infection. An array of optic symptoms can develop, most commonly anterior uveitis, but conjunctivitis, even with injection similar to Leptospirois, may develop (Fig. 59.2) [9]. In patients with Dengue Fever the presence of arthritis is not as common, whereas hemorrhagic manifestations and shock are more frequent when compared to patients with Chikungunya. Table 59.1 compares the presentation of Chikungunya to that of Dengue.

The patient was initially managed with IV crystalloid administration in the emergency department. After a bolus of 20 cc/Kg her blood pressure returned to normal. Acetaminophen was used to control her temperature and arthralgias. Tests for serology were drawn. ELISA IgM for Chikungunya infection was reported as positive, ELISA IgM for Dengue and Leptospirosis were reported as negative. Tests for malaria were also reported negative. The patient, already stable, was admitted to the hospital and 4 days later was discharged home [1–3, 6].