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

Dengue Fever Management

Initial Assessment and Risk Stratification

The cornerstone of dengue management is early recognition of warning signs, aggressive fluid resuscitation when indicated, and avoidance of NSAIDs—there is no specific antiviral therapy available. 1, 2

Immediately assess for warning signs that indicate potential progression to severe dengue: 3

• Persistent vomiting
• Severe abdominal pain or tenderness
• Clinical fluid accumulation (ascites, pleural effusion)
• Mucosal bleeding
• Lethargy or restlessness
• Hepatomegaly >2 cm
• Rising hematocrit with concurrent rapid platelet drop

Any patient with warning signs requires hospitalization and close monitoring, as early recognition can reduce case-fatality to <0.5%. 3

Diagnostic Confirmation

Obtain appropriate testing based on timing of presentation: 1

• PCR or NS1 antigen detection for patients presenting within the first 7 days of symptoms
• IgM capture ELISA for patients with symptoms present >5-7 days

Establish baseline laboratory values with complete blood count to track platelet counts and hematocrit levels. 1

Fluid Management Strategy

For Patients WITHOUT Shock (Dengue Fever or Dengue with Warning Signs)

Ensure adequate oral hydration with >2500 mL daily intake using oral rehydration solutions. 4, 1 This aggressive oral hydration is critical during the critical phase (typically days 3-7 of illness). 3

Monitor closely for signs of plasma leakage: a 20% rise in hematocrit with continuing platelet drop is an important indicator for impending shock. 5

For Patients WITH Shock (Dengue Shock Syndrome)

Administer an initial crystalloid bolus of 20 mL/kg as rapidly as possible—this is a medical emergency requiring prompt plasma replacement. 1, 5, 6

Reassess immediately after the bolus: 6

• If hemodynamically stable: reduce fluid rate and continue close monitoring
• If still unstable after 2-3 crystalloid boluses: switch to colloid solutions (including albumin if available) 5, 6
• If persistent hypotension despite adequate fluid resuscitation: add vasopressors such as norepinephrine or dopamine 1, 6

Critical pitfall to avoid: Excessive fluid administration can lead to pulmonary edema and fluid overload—once hemodynamics stabilize and clinical improvement occurs, promptly reduce and discontinue fluids. 6

Pain and Fever Management

Use acetaminophen at standard doses as the ONLY analgesic and antipyretic. 4, 1

Absolutely avoid aspirin and NSAIDs under any circumstances due to severe bleeding risk. 4, 1 This is non-negotiable regardless of pain severity.

For severe pain unresponsive to acetaminophen, consider opioid analgesics with careful monitoring. 4

Monitoring Protocol

Perform daily complete blood count monitoring to track: 1

• Platelet counts (thrombocytopenia expected)
• Hematocrit levels (rising hematocrit indicates plasma leakage)

Frequent vital sign monitoring is essential—record heart rate, blood pressure, capillary refill time, and urine output (target >0.5 mL/kg/hour in adults). 5

Consider abdominal ultrasound if abdominal pain develops to evaluate for ascites, hepatomegaly, and exclude surgical pathology. 4

Management of Complications

Bleeding

Blood transfusion is indicated for significant bleeding with hemodynamic compromise—monitor hemoglobin and hematocrit closely. 4, 1

Prophylactic platelet transfusion is NOT recommended in the absence of active bleeding. 7

Fresh frozen plasma and platelet transfusions are reserved for patients with disseminated intravascular coagulation (DIC). 5

Pleural Effusion and Ascites

Avoid drainage of pleural effusions or ascites whenever possible, as this can precipitate severe hemorrhage and sudden circulatory collapse. 5 Manage conservatively with fluid optimization.

Persistent Fever

If fever persists beyond 5 days with hemodynamic instability, obtain blood and urine cultures and chest radiograph to evaluate for secondary bacterial infection. 1 However, do not change management based solely on fever pattern without clinical deterioration or new findings. 1

Discharge Criteria

Patients may be discharged when ALL of the following are met: 4, 1

• Afebrile for ≥48 hours without antipyretics
• Resolution or significant improvement of abdominal pain and other symptoms
• Stable hemodynamic parameters for ≥24 hours without support
• Adequate oral intake maintained
• Urine output >0.5 mL/kg/hour
• Improving laboratory parameters (platelet count rising, hematocrit stabilizing)

Post-discharge instructions: Monitor temperature twice daily and return immediately if fever ≥38°C on two consecutive readings or any warning signs develop. 1

Special Populations

Pregnant women: Acetaminophen remains the safest analgesic option; avoid all NSAIDs. 1

Children: Calculate acetaminophen dosing carefully based on weight; fluid boluses remain 20 mL/kg. 1, 5

Prevention Counseling

Educate patients that Aedes aegypti mosquitoes (day-biting) are the primary vectors—emphasize daytime mosquito avoidance strategies. 1 The relatively high frequency of dengue justifies using rapid diagnostic tests in febrile travelers from endemic areas. 8