What is the treatment for dengue fever (break bone fever)?

Treatment of Dengue Fever (Break Bone Fever)

The treatment for dengue fever is primarily supportive care with careful fluid management, acetaminophen for pain and fever, close monitoring for warning signs, and avoidance of aspirin and NSAIDs due to bleeding risk. 1

Initial Assessment and Classification

Patients with suspected dengue fever should be classified into risk groups based on:

1. Diagnostic criteria:

   • Fever plus one or more of: nausea/vomiting, rash, headache, retro-orbital pain, myalgia/arthralgia, positive tourniquet test, leukopenia, or warning signs 1
   • Laboratory findings: thrombocytopenia, leukopenia, elevated hematocrit, elevated liver enzymes 1
   • Confirmation via RT-PCR, NS1 antigen detection (acute phase), or IgM/IgG antibody testing (convalescent phase) 1

2. Warning signs requiring closer monitoring:

   • Abdominal pain/tenderness
   • Persistent vomiting
   • Clinical fluid accumulation
   • Mucosal bleeding
   • Lethargy/restlessness
   • Liver enlargement
   • Increasing hematocrit with decreasing platelet count 1

Treatment Protocol

1. Fluid Management (Critical Component)

• For patients with shock:

  • Initial crystalloid fluid bolus of 20 ml/kg as rapidly as possible
  • May need to repeat 2-3 times in profound shock
  • Continue with fluid administration rate of 5-10 ml/kg/hour, adjusted according to clinical response 1
  • Monitor vital signs every 15-30 minutes during rapid fluid administration 1

• For all patients:

  • Adjust fluid rates according to clinical response rather than using fixed protocols
  • Consider early use of colloids in severe cases with significant plasma leakage 1
  • Monitor for signs of fluid overload: increasing respiratory rate with normal/falling hematocrit, new crackles on lung examination, rising JVP, new hepatomegaly, peripheral edema 1

2. Symptomatic Treatment

• For fever and pain:

  • Use acetaminophen (paracetamol) 1
  • Avoid aspirin and NSAIDs due to increased bleeding risk 1, 2

• For hypoxia:

  • Administer oxygen to all shock patients 1

3. Monitoring Requirements

• Frequent vital sign assessment
• Serial hematocrit determinations
• Urine output monitoring
• Cardiac function assessment in patients with persistent hypotension despite adequate hydration 1

4. Special Populations

• Children:

  • Require closer monitoring
  • More susceptible to fluid overload
  • Initial fluid bolus of 20 mL/kg for dengue shock syndrome
  • Regular reassessment to detect deterioration or fluid overload early 1

• Pregnant women:

  • Higher risk of complications
  • Require more intensive surveillance 1

• Older adults:

  • Higher risk of severe dengue due to comorbidities
  • May require more aggressive management 1

Discharge Criteria

Patients can be discharged when:

• No fever for 48 hours without antipyretics
• Improving clinical status
• Increasing platelet count
• Stable hematocrit
• No respiratory distress
• Good urine output 1

Prevention of Transmission

• Protect patients from further mosquito exposure to prevent transmission 1
• Mosquito control and public education to eradicate breeding grounds 2

Common Pitfalls and Caveats

1. Fluid management challenges:

   • Both under-resuscitation and fluid overload can be dangerous
   • Adjust fluid rates based on clinical response rather than fixed protocols 1
   • Consider implementing hydration tents during epidemics to decrease hospitalizations 3

2. Myocardial dysfunction:

   • May occur in approximately 16.7% of children with dengue
   • Consider cardiac function assessment in patients with persistent hypotension despite adequate hydration 1, 4

3. Immunity misconceptions:

   • Infection with one dengue serotype only provides lifelong immunity against that specific serotype
   • Only temporary cross-immunity to other serotypes 1
   • Four distinct serotypes exist 2

4. Disease progression monitoring:

   • Dengue characteristically takes a triphasic course (febrile phase, critical phase, recovery phase) 5
   • The critical phase (days 3-7 of illness) requires the most vigilant monitoring 5

5. Medication errors:

   • Mistakenly prescribing NSAIDs or aspirin can increase bleeding risk 1, 2
   • Thymosin alpha 1 is not recommended due to lack of specific evidence 1

By following this structured approach to dengue fever management with emphasis on appropriate fluid resuscitation, careful monitoring, and avoidance of medications that increase bleeding risk, patient outcomes can be significantly improved.