Comprehensive Management of Dengue Fever
The management of dengue fever requires early diagnosis through appropriate laboratory testing, supportive care focused on fluid management, careful monitoring for warning signs, and avoidance of NSAIDs, with special attention to high-risk populations including pregnant women, children, and older adults. 1
Diagnosis
Clinical Presentation
- Suspect dengue in patients with fever plus one or more of:
- Nausea/vomiting
- Rash
- Headache
- Retro-orbital pain
- Myalgia/arthralgia
- Positive tourniquet test
- Leukopenia
- Warning signs of severe disease 1
Epidemiological Factors
- Recent travel to or residence in endemic areas (tropical/subtropical regions)
- Sexual contact with someone who lives in or traveled to endemic areas 1
Laboratory Testing
- First-line testing: Dengue virus nucleic acid amplification tests (NAATs) on serum 1
- Acute phase (0-7 days):
- RT-PCR for dengue virus RNA
- NS1 antigen detection 1
- Convalescent phase (>7 days):
- IgM antibody detection
- Demonstration of fourfold rise/fall in IgG or IgM antibody titers in paired samples 1
- Supporting laboratory findings:
- Thrombocytopenia (low platelet count)
- Leukopenia
- Elevated hematocrit (indicating hemoconcentration)
- Elevated liver enzymes 1
Treatment and Management
Fluid Management
- Initial approach: Crystalloids at 5-10 ml/kg/hour, adjusting according to clinical response 1
- Severe cases: Consider early use of colloids in patients with significant plasma leakage 1
- Children with dengue shock syndrome: Initial fluid bolus of 20 mL/kg 1
Symptomatic Treatment
- For fever and pain: Use acetaminophen (paracetamol) 1
- Avoid: Aspirin and NSAIDs due to risk of bleeding complications 1
Prevention of Transmission
- Protect patients with dengue from further mosquito exposure 1
Monitoring and Follow-up
Baseline Evaluation
- Accurate weight documentation
- Vital sign assessment including pulse pressure
- Baseline hematocrit check
- Urine output measurement
- Respiratory status assessment 1
Ongoing Monitoring
- Monitor vital signs every 15-30 minutes during rapid fluid administration 1
- Watch for warning signs:
- Abdominal pain or tenderness
- Persistent vomiting
- Clinical fluid accumulation
- Mucosal bleeding
- Lethargy or restlessness
- Liver enlargement
- Increasing hematocrit with rapid decrease in platelet count 1
Signs of Fluid Overload
- Increasing respiratory rate with normal/falling hematocrit
- Development of new crackles on lung examination
- Rising JVP
- New onset hepatomegaly
- Peripheral edema 1
Discharge Criteria
- No fever for 48 hours without antipyretics
- Improving clinical status
- Increasing platelet count
- Stable hematocrit
- No respiratory distress
- Good urine output 1
Special Populations
Pregnant Women
- Higher risk of complications
- Require more intensive surveillance 1
Children
- More susceptible to fluid overload
- Require closer monitoring
- Need adjusted fluid management 1
Older Adults
- Higher risk of developing severe dengue due to comorbidities
- May require more aggressive management 1
Patients with Comorbidities
- Require closer monitoring and potentially adjusted fluid management 1
Complications and Prognosis
Potential Complications
- Dengue hemorrhagic fever
- Dengue shock syndrome
- Multiple organ failure
- Disseminated intravascular coagulation 2
Prognosis
- Complete recovery from mild dengue typically occurs without long-term sequelae 1
- Severe dengue can be life-threatening due to increased vascular permeability 2
Important Considerations
Immunity
- Infection with one dengue serotype provides lifelong immunity against that specific serotype only
- Only temporary cross-immunity to other serotypes
- Secondary infection with a different serotype increases risk of severe disease 1, 2
Pitfalls to Avoid
- Do not use fixed fluid protocols - adjust rates according to clinical response 1
- Do not miss warning signs of severe disease or fluid overload 1
- Do not use NSAIDs for pain or fever management 1
- Do not discharge patients prematurely before meeting all discharge criteria 1
The management of dengue fever remains primarily supportive, with no specific antiviral therapy currently available 3. Effective fluid replacement is the cornerstone of management for severe cases 2. Vector control and vaccination development represent important future directions for dengue prevention 2, 3.