What is the management approach for dengue (Dengue fever)?

Dengue Fever Management Guidelines

The management of dengue fever is primarily supportive, focusing on adequate hydration, careful monitoring, and appropriate pain control with acetaminophen while avoiding NSAIDs due to bleeding risk. 1, 2

Clinical Presentation and Diagnosis

• Dengue presents with fever, headache, retro-orbital pain, severe myalgia, arthralgia, and rash, with an incubation period of 4-8 days 1
• Diagnosis is confirmed by PCR (most effective in first few days) or IgM capture ELISA (appropriate after first week of illness) 1, 3
• NS1 antigen detection is useful in the acute phase, detectable from day 1 to day 10 after symptom onset 3

Risk Stratification and Monitoring

• Daily complete blood count monitoring is essential to track platelet counts and hematocrit levels 1
• Warning signs requiring immediate attention include:
  • Persistent vomiting, abdominal pain/tenderness
  • Clinical fluid accumulation (pleural effusion, ascites)
  • Mucosal bleeding
  • Lethargy/restlessness
  • Hepatomegaly
  • Rising hematocrit with concurrent falling platelet count 3
• Warning signs typically appear around days 3-7 of illness, coinciding with defervescence 3
• A rise in hematocrit of 20% along with continuing drop in platelet count indicates impending shock 4

Fluid Management

For Patients Without Shock

• Ensure adequate oral hydration (>2500mL daily) 1
• Use oral rehydration solutions for moderate dehydration 1
• Rest is an essential component of management 5

For Dengue Shock Syndrome

• Administer initial fluid bolus of 20 mL/kg with careful reassessment afterward 1
• Crystalloids are the fluid of choice for initial management 6
• If patients are unresponsive to crystalloids despite adequate resuscitation, switch to colloids 6
• For persistent tissue hypoperfusion despite adequate fluid resuscitation, consider vasopressors such as norepinephrine 1, 6

Pain 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 5, 1
• Monitor liver function tests when using acetaminophen, particularly in patients with pre-existing liver disease or signs of hepatic involvement 5
• Avoid aspirin and NSAIDs due to increased bleeding risk 5, 1

Management of Complications

• For significant bleeding, blood transfusion may be necessary 1
• Prophylactic platelet transfusion is not recommended 2
• Polyserositis (pleural effusion and ascites) are common in dengue shock syndrome; drainage should be avoided when possible as it can lead to severe hemorrhages and sudden circulatory collapse 4
• Secondary hemophagocytic lymphohistiocytosis is a potentially fatal complication requiring specific management with steroids or intravenous immunoglobulin 2

Special Populations

• For pregnant women, acetaminophen remains the safest analgesic option 5
• In children, acetaminophen dosing should be carefully calculated based on weight (10-15 mg/kg per dose) 5, 1

Common Pitfalls to Avoid

• Never use aspirin or NSAIDs due to high bleeding risk 5, 1
• Do not delay fluid resuscitation in patients showing signs of shock 5, 1
• Avoid failing to recognize the critical phase (typically days 3-7 of illness) when plasma leakage can rapidly progress to shock 5
• After stabilizing hemodynamics and clinical improvement, be careful to reduce and discontinue fluids appropriately to avoid congestion and other complications 6

Emerging Treatments

• Currently, there is no effective vaccine or licensed antiviral therapy for dengue 7, 2
• Studies have shown that corticosteroids, carbazochorome sodium sulfonate, and recombinant activated factor VII did not reduce mortality in children with hemorrhagic dengue 8
• Research on direct antiviral therapies is ongoing but remains a work in progress 7