How to manage a patient with vertigo and dengue?

Management of Vertigo in Patients with Dengue

For patients with dengue who develop vertigo, treatment should focus on managing both the underlying dengue infection and the vertigo symptoms, with careful attention to avoiding medications that may worsen dengue complications such as bleeding or hypotension.

Diagnosis and Assessment

Determine if Vertigo is Related to Dengue

• Vertigo in dengue patients may be due to:
  • Direct neurological manifestations of dengue infection 1
  • Intracranial hemorrhage (rare but serious complication) 2
  • Coincidental peripheral vestibular disorders (e.g., BPPV)
  • Medication side effects
  • Dehydration or electrolyte imbalances

Key Diagnostic Steps

1. Targeted physical examination:

   • HINTS examination (Head-Impulse, Nystagmus, Test of Skew) to distinguish peripheral from central causes 3
   • Dix-Hallpike maneuver to assess for BPPV 3
   • Check for focal neurological deficits suggesting intracranial complications

2. Laboratory investigations:

   • Complete blood count with platelet count
   • Coagulation profile (PT/INR, aPTT)
   • Dengue diagnostic testing (NAAT for dengue virus within 7 days of symptom onset) 4
   • Electrolytes and renal function

3. Imaging when indicated:

   • MRI head (preferred) if central vertigo is suspected or neurological deficits are present 3
   • CT scan if MRI unavailable or in emergency situations with rapid deterioration 2

Management Algorithm

1. Dengue-Specific Management

• Monitor for signs of plasma leakage, shock, and hemorrhage 4
• Maintain adequate hydration with IV fluids if needed
• Monitor platelet counts and coagulation parameters
• Avoid aspirin and NSAIDs due to bleeding risk

2. Vertigo Symptom Management

Acute Symptomatic Relief

• Vestibular suppressants: Use with caution and only for short-term relief
  • Antiemetics: Prefer prokinetic antiemetics like metoclopramide (5-10mg) or domperidone (10mg) that have less CNS effects 3
  • If benzodiazepines are needed for severe symptoms, use lowest effective dose for shortest duration (e.g., diazepam 2-5mg)

If BPPV is diagnosed

• Canalith repositioning procedures:
  • Epley maneuver for posterior canal BPPV
  • Barbecue roll or Gufoni maneuver for horizontal canal BPPV 3
  • These are safe, non-pharmacological interventions with 80-90% success rate

If central vertigo or neurological complications

• Urgent neurology consultation
• Consider neurosurgical consultation if intracranial hemorrhage is detected 2
• Platelet transfusions if platelet count <50,000/μL and active bleeding or high-risk procedures needed 4

3. Special Considerations in Dengue

• Fluid management: Balance between adequate hydration and risk of fluid overload
• Bleeding risk: Monitor for signs of intracranial hemorrhage (altered mental status, focal deficits)
• Medication cautions:
  • Avoid medications that may mask fever or cause sedation
  • Avoid medications with potential for hepatotoxicity

Monitoring and Follow-up

• Monitor vital signs, neurological status, and platelet counts frequently
• Reassess vertigo symptoms daily
• For patients with intracranial complications, close neurological monitoring is essential
• Follow up within 1 month after resolution of dengue to ensure complete resolution of vertigo 3

Warning Signs Requiring Urgent Attention

• Rapid deterioration in neurological status
• New onset headache or altered mental status
• Focal neurological deficits
• Signs of increased intracranial pressure
• Persistent vomiting
• Evidence of bleeding

Pitfalls and Caveats

• Don't attribute all neurological symptoms to "dengue encephalopathy" without proper evaluation
• Vertigo with altered mental status should not be dismissed as fever delirium 2
• Intracranial hemorrhage can occur even during convalescence phase of dengue 2
• Avoid overuse of vestibular suppressants as they may interfere with compensation and recovery 3
• Consider that vertigo may be the first presentation of a more serious neurological complication of dengue

By following this structured approach, clinicians can effectively manage patients with vertigo in the context of dengue infection, reducing morbidity and potentially preventing mortality from serious neurological complications.