What is the management and treatment of dengue (Dengue virus infection)?

Management and Treatment of Dengue Fever

The management of dengue fever primarily involves supportive care with acetaminophen for pain and fever, adequate hydration, careful monitoring for warning signs, and avoidance of aspirin and NSAIDs due to increased bleeding risk. 1, 2

Clinical Presentation and Diagnosis

• Dengue presents with a spectrum ranging from mild febrile illness to dengue hemorrhagic fever (DHF) or dengue shock syndrome (DSS), with an incubation period of 4-8 days 1, 2
• Common symptoms include fever, headache, retro-orbital pain, severe myalgia, arthralgia, and rash 3, 2
• Diagnosis is confirmed by positive PCR (early in disease) or IgM capture ELISA (after 5-7 days of symptoms) 1, 2
• For patients with possible exposure to both dengue and Zika virus, nucleic acid amplification tests (NAATs) should be performed on serum collected ≤7 days after symptom onset 4

Classification and Risk Stratification

• According to WHO criteria, dengue is classified into dengue fever, dengue hemorrhagic fever (DHF), and dengue shock syndrome (DSS) 5
• Dengue hemorrhagic fever is defined by minor or major bleeding phenomena, thrombocytopenia (≤100,000/mm³), and evidence of plasma leakage 4
• Dengue shock syndrome includes all criteria for DHF plus hypotension or narrow pulse pressure (≤20 mm Hg) 4
• Monitor for warning signs of severe dengue, including persistent vomiting, abdominal pain, lethargy, restlessness, mucosal bleeding, and rising hematocrit with falling platelet count 1, 2

Monitoring Recommendations

• Daily complete blood count monitoring is essential to track platelet counts and hematocrit levels 3, 1, 2
• Recognize the critical phase (typically days 3-7 of illness) when plasma leakage can rapidly progress to shock 3
• For patients with possible exposure to both dengue and Zika virus, testing algorithms should include both viral detection and antibody testing 4

Treatment Approach

Fluid Management

• For patients without shock, ensure adequate oral hydration with more than 2500ml daily 1, 2
• For moderate dehydration, oral rehydration solution (ORS) should be given 3
• For dengue shock syndrome, administer an initial fluid bolus of 20 mL/kg crystalloid with careful reassessment afterward 1, 2
• Consider using colloid solutions for severe shock when crystalloids are ineffective 2

Pain and Fever Management

• Acetaminophen (paracetamol) at standard doses (10-15 mg/kg every 4-6 hours, not exceeding 4 g/day in adults) is recommended for pain and fever relief 3, 1, 2
• Monitor liver function tests when using acetaminophen, particularly in patients with pre-existing liver disease or signs of hepatic involvement 3
• Avoid aspirin and NSAIDs under any circumstances due to increased bleeding risk 3, 1, 2

Management of Complications

• For significant bleeding, blood transfusion may be necessary 1, 2
• For persistent tissue hypoperfusion despite adequate fluid resuscitation, vasopressors such as dopamine or epinephrine may be required 1
• For respiratory distress and/or persistent hypoxemia, consider non-invasive ventilation if available 1
• If intubation is necessary, ketamine with atropine premedication is suggested for sedation to maintain cardiovascular stability 1

Special Populations

• For pregnant women with dengue fever, acetaminophen remains the safest analgesic option 3, 2
• In children, acetaminophen dosing should be carefully calculated based on weight (10-15 mg/kg per dose) 3, 2
• Careful fluid management is particularly important in children with dengue shock syndrome 1

Common Pitfalls to Avoid

• Do not use aspirin or NSAIDs under any circumstances due to high bleeding risk 3, 1, 2
• Avoid delaying fluid resuscitation in patients showing signs of shock 3, 2
• Do not fail to recognize the critical phase when plasma leakage can rapidly progress to shock 3
• Avoid excessive fluid administration, which can lead to pulmonary edema, particularly in the recovery phase 1

Emerging Treatments and Prevention

• Currently, there is no effective antiviral therapy specifically for dengue, and management remains primarily supportive 6, 7
• Recent advances include development of direct antivirals and host-targeted drugs to reduce inflammation and vascular pathologies 8
• Vector control targeting Aedes mosquitoes (particularly Aedes aegypti) remains a key prevention strategy 2, 9
• Dengvaxia (by Sanofi Pasteur) is the first licensed dengue vaccine, though it has limitations and is recommended primarily for those with prior dengue infection 5