Dengue Fever: Diagnosis and Management
Dengue fever requires careful monitoring for warning signs with acetaminophen for pain management and adequate fluid resuscitation as the cornerstone of treatment, while avoiding NSAIDs due to bleeding risk. 1
Clinical Presentation
- Dengue presents as a spectrum from mild febrile illness to dengue hemorrhagic fever (DHF) or dengue shock syndrome (DSS), with an incubation period of 4-8 days 1
- Classic symptoms include fever, headache, retro-orbital pain, myalgia, arthralgia, and rash 1, 2
- The disease typically follows a triphasic course: febrile phase, critical phase, and recovery phase 3
Warning Signs Requiring Immediate Attention
- Persistent vomiting, abdominal pain/tenderness, clinical fluid accumulation 4
- Mucosal bleeding, lethargy/restlessness 4
- Hepatomegaly 4
- Hematocrit rise with concurrent thrombocytopenia 4
- Warning signs typically appear around day 3-7 of illness, coinciding with defervescence 4
Diagnostic Approach
- For patients with possible dengue exposure, nucleic acid amplification tests (NAATs) should be performed on serum collected ≤7 days after symptom onset 5, 2
- PCR testing is most effective in the first few days of infection during viremia 4, 2
- NS1 antigen detection is useful in the acute phase, detectable from day 1 to day 10 after symptom onset 4, 2
- IgM antibody testing becomes appropriate after the first week of illness 4, 2
- In areas with risk for both dengue and Zika virus, testing for both viruses should be considered 5
Laboratory Findings
- Thrombocytopenia, leukopenia, and raised hematocrit levels are the most significant hematological parameters when assessing severity 6
- Patients with severe dengue show marked thrombocytopenia, with platelet counts often below 50 × 10^9/L 6
Management
Fluid Management
- For patients without shock: ensure adequate oral hydration and use oral rehydration solutions for moderate dehydration, aiming for more than 2500ml daily 1
- For dengue shock syndrome: administer an initial fluid bolus of 20 mL/kg with careful reassessment afterward 1
- Consider using colloid solutions for severe shock when available 1
Pain Management
- Acetaminophen at standard doses is recommended for pain and fever relief 1
- Avoid aspirin and NSAIDs under any circumstances due to increased bleeding risk 1
Monitoring
- Daily complete blood count monitoring is essential to track platelet counts and hematocrit levels 1
- Monitor for warning signs of severe dengue, including persistent vomiting, abdominal pain, lethargy, restlessness, mucosal bleeding, and rising hematocrit with falling platelet count 1
Management of Complications
- For significant bleeding, blood transfusion may be necessary 1
- For persistent tissue hypoperfusion despite adequate fluid resuscitation, vasopressors such as dopamine or epinephrine may be required 1
Special Populations
- Pregnant women face potential complications from dengue infection, including increased risk for maternal death or obstetric complications (hemorrhage, preeclampsia, eclampsia, and vertical transmission) 5
- For pregnant women, acetaminophen remains the safest analgesic option 1
- In children, acetaminophen dosing should be carefully calculated based on weight 1
Prevention
- Day-biting mosquitoes of the genus Aedes, particularly Aedes aegypti, are the primary vectors of dengue fever 1, 7
- Prevention depends on control of the mosquito vector 8
- Meticulous avoidance of mosquito bites is essential 3