What is the management of dengue fever?

Management of Dengue Fever

Dengue fever management should focus on supportive care with careful fluid management, monitoring for warning signs, and avoiding NSAIDs, with no specific antiviral treatment currently available. 1

Clinical Classification and Diagnosis

Dengue presents as an acute febrile illness with:

• High fever, severe headache, retro-orbital pain
• Muscle/joint pain, rash
• Leucopenia, progressive thrombocytopenia, elevated liver enzymes

Diagnosis is made by:

• Acute phase (≤7 days): RT-PCR for dengue virus RNA or NS1 antigen detection
• Convalescent phase (>5-7 days): IgM antibody detection or demonstration of fourfold rise/fall in IgG/IgM antibody titers 1

Severe forms include:

• Dengue hemorrhagic fever: hemorrhagic phenomena, platelets ≤100,000/mm³, evidence of plasma leakage
• Dengue shock syndrome: all criteria for hemorrhagic fever plus hypotension and narrow pulse pressure (≤20 mm Hg) 1

Management Approach

1. Supportive Care

• Hydration: Critical component of management
  • Oral rehydration for mild cases without signs of shock
  • Parenteral fluids for more severe cases 1, 2
• Pain and fever control: Acetaminophen/paracetamol only
  • Avoid NSAIDs and aspirin due to increased bleeding risk 1
• Rest and symptomatic relief

2. Fluid Management

Fluid therapy varies by severity:

For Non-Severe Cases:

• Encourage oral fluids
• Monitor urine output (goal: >0.5 mL/kg/hour in adults, >1 mL/kg/hour in children) 1

For Dengue with Warning Signs:

• Crystalloid fluids (5-10 mL/kg/hour)
• Adjust based on clinical response and laboratory parameters 1, 3

For Dengue Shock Syndrome:

• Immediate fluid resuscitation: Crystalloids as initial bolus (20 mL/kg) 1
• May require 2-3 boluses in profound shock 4
• Consider colloids for patients with massive plasma leakage or unresponsive to crystalloids 4, 5
• Place patient in semi-recumbent position (head elevated 30-45°) 1

3. Monitoring

Frequent monitoring is essential:

• Vital signs (especially blood pressure and pulse)
• Hematocrit (rise of ≥20% indicates significant plasma leakage)
• Platelet count
• Fluid balance
• Warning signs: abdominal pain, persistent vomiting, fluid accumulation, mucosal bleeding, lethargy, hepatomegaly 1, 4

4. Management of Complications

Severe Bleeding:

• Blood product transfusion as needed
• No prophylactic platelet transfusion recommended 1, 3

Persistent Shock:

• Consider vasopressors (dopamine, epinephrine) if shock persists despite adequate fluid replacement
• Norepinephrine for excessive peripheral vasodilation 1, 5

Organ Involvement:

• Identify and manage organ dysfunction
• Oxygen therapy is mandatory in all shock patients 4
• Avoid drainage of pleural effusion/ascites if possible (risk of hemorrhage and circulatory collapse) 4

Secondary Hemophagocytic Lymphohistiocytosis:

• Consider steroids or intravenous immunoglobulin in confirmed cases 3

Prognosis and Prevention

With proper management, mortality can be reduced to less than 0.5% even in hospitalized patients 1. Early recognition and treatment of shock is the key prognostic factor 4.

Prevention measures include:

• Vector control (elimination of mosquito breeding sites)
• Personal protection (repellents, appropriate clothing, mosquito nets)
• Vaccination in endemic areas for those with confirmed previous dengue infection 1

Common Pitfalls to Avoid

1. Excessive fluid administration: Can lead to fluid overload, pulmonary edema
2. Inadequate monitoring: Failure to detect progression to severe disease
3. Use of NSAIDs/aspirin: Increases bleeding risk
4. Prophylactic platelet transfusion: Not recommended and may cause harm
5. Failure to recognize warning signs: Delays critical interventions
6. Inappropriate fluid reduction: Careful titration needed during recovery phase 5

The management of dengue requires vigilant monitoring and adjustment of treatment strategies based on the patient's clinical status, with fluid management being the cornerstone of care.