What is the management approach for adults diagnosed with dengue?

Management of Dengue in Adults

Adults with dengue require risk stratification into three groups based on warning signs and comorbidities, with management centered on meticulous fluid management, acetaminophen for symptom control, and strict avoidance of NSAIDs and aspirin. 1, 2

Initial Assessment and Risk Stratification

Clinical Presentation

• Dengue presents with fever, headache, retro-orbital pain, myalgia, arthralgia, and rash, with an incubation period of 4-8 days 1, 2
• The disease follows a characteristic triphasic course: febrile phase, critical phase (typically days 3-7), and recovery phase 3
• More than 90% of cases follow a mild course, but severe dengue with shock or hemorrhage carries 1-5% mortality 3

Diagnostic Confirmation

• Perform PCR or nucleic acid amplification testing on serum collected within the first 7 days of symptom onset 1, 2
• After 5-7 days of symptoms, use IgM capture ELISA for diagnosis 1, 2
• Dengue NS1 antigen can be detected in serum with similar frequency and duration as viral RNA 4

Identify High-Risk Patients

• Adults aged 60 years or older are at significantly increased risk for severe organ involvement 5
• Pre-existing diabetes, cardiac disorders, and asthma independently increase risk of progression to severe disease 5
• Patients with two or more comorbidities require heightened vigilance 5

Monitoring Protocol

Daily Laboratory Surveillance

• Obtain complete blood count daily to track platelet counts and hematocrit levels 1, 6, 2
• Rising hematocrit with falling platelet count signals plasma leakage and impending severe disease 6, 2

Warning Signs Requiring Immediate Escalation

• Persistent vomiting preventing adequate oral intake 1, 6, 2
• Severe abdominal pain (may indicate hepatomegaly, plasma leakage with ascites, or gastrointestinal bleeding) 1, 6, 2
• Lethargy or restlessness indicating altered mental status 6, 2
• Mucosal bleeding (gums, nose, gastrointestinal tract) 6, 2
• Clinical fluid accumulation (ascites, pleural effusion) detected on examination 6, 5

Fluid Management Strategy

Patients Without Shock

• Ensure oral hydration exceeding 2500 mL daily 1, 6, 2
• Use oral rehydration solutions for moderate dehydration 2
• This aggressive oral hydration is critical during the critical phase when plasma leakage occurs 1

Dengue Shock Syndrome

• Administer immediate fluid bolus of 20 mL/kg crystalloid solution 1, 6, 2
• Reassess hemodynamic status carefully after each bolus 1, 6, 2
• Consider colloid solutions for severe shock when available 2
• For persistent tissue hypoperfusion despite adequate fluid resuscitation, initiate vasopressors (dopamine or epinephrine) 1, 2

Symptom Management

Pain and Fever Control

• Acetaminophen at standard doses is the only acceptable analgesic for dengue 1, 6, 2
• Absolutely avoid aspirin and NSAIDs under any circumstances due to dramatically increased bleeding risk 1, 6, 2, 7
• For severe pain unresponsive to acetaminophen, consider opioid analgesics with careful monitoring 6

What NOT to Use

• Corticosteroids have no proven benefit in dengue shock or early-stage dengue and should not be used outside clinical trials 8
• The evidence for corticosteroids is inconclusive with very low quality, showing no effect on mortality, shock prevention, or bleeding complications 8

Management of Complications

Hemorrhagic Manifestations

• For significant bleeding, transfuse blood products as necessary 1, 6, 2
• Monitor hemoglobin and hematocrit closely in bleeding patients 6
• Dengue hemorrhagic fever is defined by bleeding phenomena, thrombocytopenia (platelets <100,000/mm³), and evidence of plasma leakage 2

Respiratory Complications

• For respiratory distress with persistent hypoxemia despite oxygen therapy, consider non-invasive ventilation if staff is adequately trained 1
• If intubation becomes necessary, use ketamine with atropine premedication to maintain cardiovascular stability 1

Abdominal Complications

• Obtain abdominal ultrasound to evaluate for ascites, hepatomegaly, and exclude surgical pathology 6
• Senior surgical consultation is essential for suspected surgical emergencies 6
• Consider conservative management when appropriate, as many abdominal findings are dengue-related rather than surgical 6

Cardiovascular Monitoring

• Use continuous cardiac telemetry and pulse oximetry for patients with dengue shock syndrome 2
• Maintain stable hemodynamic parameters for at least 24 hours before considering discharge 6, 2

Discharge Criteria

Patients may be discharged when ALL of the following criteria are met: 6, 2

• Afebrile for at least 48 hours without antipyretics 6, 2
• Resolution or significant improvement of abdominal pain and other symptoms 6, 2
• Stable hemodynamic parameters for at least 24 hours (normal heart rate, blood pressure, capillary refill) without support 2
• Adequate oral intake maintained 6, 2
• Adequate urine output (>0.5 mL/kg/hour in adults) 2
• Laboratory parameters returning toward normal ranges 6, 2
• Improved general condition and return to baseline mental status 2

Post-Discharge Instructions

• Monitor and record temperature twice daily 2
• Return immediately if temperature rises to ≥38°C on two consecutive readings 2
• Return for any warning signs: persistent vomiting, severe abdominal pain, bleeding, lethargy, or restlessness 2

Critical Pitfalls to Avoid

• Never use NSAIDs or aspirin—this is the most dangerous error in dengue management 1, 6, 2, 7
• Do not delay fluid resuscitation in patients showing any signs of shock 6, 2
• Do not fail to recognize abdominal pain as a warning sign of progression to severe dengue 6
• Avoid inadequate monitoring during the critical phase (days 3-7 of illness) 6
• Do not change management based solely on persistent fever without clinical deterioration or new findings 2
• Do not discharge patients before meeting all discharge criteria, particularly hemodynamic stability for 24 hours 6, 2

Special Considerations

• Pregnant women with dengue should receive acetaminophen as the safest analgesic option 1, 2
• Careful fluid management is particularly important in elderly patients and those with cardiac comorbidities 5
• Currently, no effective antiviral therapy exists for dengue; management remains entirely supportive 9, 3
• With appropriate clinical management, case-fatality rates among hospitalized patients can be reduced to less than 0.5% 4