How to manage persistent fever in Dengue (Dengue fever)?

Management of Persistent Fever in Dengue

Persistent fever alone in a patient with dengue whose condition is otherwise stable rarely requires changes to the initial management approach and should be continued until fever resolves, typically within 5 days of treatment initiation. 1, 2

Assessment of Persistent Fever in Dengue

• Persistent fever is common in dengue and typically resolves within 5 days of treatment initiation 1
• Daily monitoring is essential, including complete blood count to track platelet counts and hematocrit levels 2
• Watch for warning signs of severe dengue alongside persistent fever, including:
  • Persistent vomiting
  • Abdominal pain
  • Lethargy or restlessness
  • Mucosal bleeding
  • Rising hematocrit with falling platelet count 2

Management Approach

Fluid Management

• Ensure adequate oral hydration with more than 2500ml daily for patients without shock 2
• Use oral rehydration solutions for moderate dehydration 2
• Consider using a fluid chart to monitor intake, which may help reduce hospitalization and IV fluid requirements 3
• For patients with signs of shock, administer an initial fluid bolus of 20 mL/kg crystalloid with careful reassessment 4

Symptomatic Management

• Acetaminophen at standard doses is recommended for pain and fever relief 2, 4
• Avoid aspirin and NSAIDs under any circumstances due to increased bleeding risk 2, 4, 5
• Maintain close monitoring of vital signs and laboratory parameters despite persistent fever 1, 2

Management of Complications

• For significant bleeding, blood transfusion may be necessary 4
• For persistent tissue hypoperfusion despite adequate fluid resuscitation, consider vasopressors such as dopamine or epinephrine 4
• Polyserositis (pleural effusion and ascites) is common in severe cases and drainage should be avoided when possible to prevent hemorrhages and circulatory collapse 6

Criteria for Hospital Admission or Escalation of Care

• Patients with any warning signs warrant close monitoring and consideration for hospitalization 7
• Patients who remain hemodynamically unstable should have their management broadened to include coverage for potential secondary infections 1
• Severe dengue with shock and/or mucosal hemorrhages requires immediate hospitalization 8

Discharge Criteria

• Patients can be discharged when:
  • Afebrile for at least 48 hours without antipyretics 2
  • Symptoms have significantly improved 2
  • Laboratory parameters are returning to normal 2
  • Hemodynamically stable for at least 24 hours without support 2
  • Adequate urine output (>0.5 mL/kg/hour in adults) 2

Post-Discharge Instructions

• Monitor and record temperature twice daily 2
• Return to healthcare facility if temperature rises to ≥38°C on two consecutive readings or if warning signs develop 2
• Continue adequate oral fluid intake 2, 3

Common Pitfalls to Avoid

• Changing antibiotics or management based solely on persistent fever pattern without clinical deterioration or new findings 1
• Using NSAIDs for fever control, which can increase bleeding risk 2, 4, 5
• Delaying fluid resuscitation in patients showing signs of shock 2
• Inadequate monitoring of hematocrit and platelet counts 2, 9