What is the recommended treatment for Dengue fever syndrome?

Treatment of Dengue Fever Syndrome

For dengue shock syndrome, administer an initial fluid bolus of 20 mL/kg of isotonic crystalloid solution (normal saline or Ringer's lactate) over 5-10 minutes with immediate reassessment, and consider colloid solutions if shock persists after adequate crystalloid resuscitation. 1, 2, 3

General Management Principles

Symptomatic management is the cornerstone of treatment, as no specific antiviral therapy exists. 3, 4

• Use acetaminophen for fever and pain control at standard doses 2
• Absolutely avoid aspirin and NSAIDs due to significantly increased bleeding risk and potential for worsening thrombocytopenia 2, 3, 5
• Daily complete blood count monitoring is mandatory to track platelet counts and hematocrit levels, particularly during the critical phase (days 3-7 of illness) 2, 3

Fluid Management Strategy

For Patients WITHOUT Shock

• Oral rehydration is first-line treatment, aiming for >2500 mL daily intake 2, 3
• Use oral rehydration solutions for moderate dehydration 2
• Avoid routine bolus IV fluids in patients with severe febrile illness who are not in shock, as moderate-quality evidence shows harm (RR 0.76,95% CI 0.68-0.85) 1, 3, 5

For Dengue Shock Syndrome (DSS)

Initial resuscitation:

• Administer 20 mL/kg isotonic crystalloid bolus (normal saline or Ringer's lactate) over 5-10 minutes 1, 2, 3, 6, 7
• Reassess immediately after each bolus for signs of improvement 3, 6
• If shock persists, repeat crystalloid boluses up to 40-60 mL/kg total in the first hour 3, 6

Escalation for refractory shock:

• Switch to colloid solutions (dextran, gelafundin, or albumin) if massive plasma leakage occurs or large volumes of crystalloids have been given without adequate response 1, 3, 6, 8, 7
• Moderate-quality evidence shows colloids provide faster resolution of shock (RR 1.09,95% CI 1.00-1.19) 1, 5

Vasopressor support:

• For cold shock with hypotension: titrate epinephrine as first-line 3
• For warm shock with hypotension: titrate norepinephrine as first-line 3, 8
• Consider vasopressors when fluid overload develops (pulmonary edema) despite persistent hypotension 3, 8

Critical Monitoring Parameters

Watch for warning signs of progression to severe disease:

• High hematocrit with rapidly falling platelet count (a 20% rise in hematocrit is a critical indicator) 3, 6
• Severe abdominal pain, persistent vomiting 2, 3
• Lethargy, restlessness, altered mental status 2, 3
• Mucosal bleeding 2, 3
• Clinical fluid accumulation (ascites, pleural effusion) 5

Signs of adequate resuscitation:

• Normal capillary refill time (<2 seconds) 3, 5
• Warm, dry extremities with well-felt peripheral pulses 3, 5
• Return to baseline mental status 3, 5
• Adequate urine output (>0.5 mL/kg/hour in adults) 2, 3
• Absence of skin mottling 3, 5

Signs of fluid overload (stop aggressive fluids immediately):

• Hepatomegaly 3
• Rales on lung examination 3
• Respiratory distress 3

Management of Complications

• For significant bleeding: blood transfusion may be necessary; consider fresh frozen plasma and platelet transfusions if DIC develops 2, 3, 5, 6
• For pleural effusion/ascites: avoid drainage if possible, as it can precipitate severe hemorrhage and sudden circulatory collapse 6
• For persistent fever: obtain blood/urine cultures and chest radiograph to rule out secondary bacterial infection 2

Critical Pitfalls to Avoid

• Do NOT continue aggressive fluid resuscitation once signs of fluid overload appear—switch to inotropic/vasopressor support instead 3
• Do NOT use restrictive fluid strategies in established dengue shock syndrome—this approach shows no survival benefit and aggressive fluid management improves outcomes 3
• Do NOT administer excessive fluid boluses in patients without shock—this leads to fluid overload and respiratory complications 3, 5
• Do NOT fail to recognize the critical phase (days 3-7) when plasma leakage can rapidly progress to shock 3, 5
• Do NOT delay fluid resuscitation in patients showing signs of shock 2, 3, 5

Discharge Criteria

Patients can be discharged when ALL of the following are met:

• Afebrile for ≥48 hours without antipyretics 2
• Stable hemodynamics for ≥24 hours without support 2
• Laboratory values returning to normal ranges 2
• Adequate urine output (>0.5 mL/kg/hour) 2
• Resolution or significant improvement of symptoms 2

Post-discharge instructions: Monitor temperature twice daily and return immediately if fever ≥38°C on two consecutive readings or any warning signs develop 2