Management of Rash with Dengue Fever
For patients presenting with rash and suspected dengue fever, manage symptomatically as an outpatient with daily complete blood count monitoring unless there are warning signs of severe disease (high hematocrit, falling platelets, persistent vomiting, severe abdominal pain, or mucosal bleeding), in which case hospitalization is required. 1, 2
Diagnostic Confirmation
- Confirm diagnosis with dengue PCR for patients within 1-8 days of symptom onset 1
- For symptoms present >5-7 days, use IgM capture ELISA 1, 2
- The rash in dengue typically appears during the febrile phase and is characteristic of the disease, often accompanied by fever, headache, retro-orbital pain, myalgia, and arthralgia 1
Risk Stratification and Monitoring
Daily FBC monitoring is essential to identify patients at high risk of progression to dengue hemorrhagic fever or shock syndrome 1, 2:
- Monitor for rising hematocrit (>20% increase from baseline) with falling platelet counts 2, 3
- Watch for warning signs: persistent vomiting, severe abdominal pain, lethargy, restlessness, mucosal bleeding 2, 3
- Severe dengue (DHF/DSS) is rare in travelers but carries 1-5% mortality when it occurs 4
Symptomatic Management
Pain and Fever Control
- Use acetaminophen/paracetamol at standard doses only 2, 3, 5
- Absolutely avoid aspirin and NSAIDs due to increased bleeding risk with thrombocytopenia 1, 2, 3, 5
Hydration Management
- Ensure adequate oral hydration with oral rehydration solutions containing electrolytes, aiming for >2500ml daily 2, 3
- For moderate dehydration with vomiting, consider nasogastric administration of 20 mL/kg oral rehydration solution with glucose every 4 hours 3
Indications for Hospitalization
Admit patients with any of the following 2, 3:
- Persistent vomiting preventing adequate oral hydration
- Rapidly decreasing platelet count
- Rising hematocrit with falling platelets
- Any warning signs of severe dengue (mucosal bleeding, severe abdominal pain, lethargy, restlessness)
- Signs of plasma leakage or shock (cold, clammy extremities, narrow pulse pressure)
Management of Severe Disease
If dengue shock syndrome develops 2:
- Administer initial fluid bolus of 20 mL/kg over 5-10 minutes with careful reassessment
- Consider colloid solutions for severe shock when available
- Monitor continuously with cardiac telemetry and pulse oximetry
- For persistent tissue hypoperfusion despite adequate fluid resuscitation, vasopressors (dopamine or epinephrine) may be required
Critical Pitfalls to Avoid
- Never delay fluid resuscitation in patients showing signs of shock 2, 3
- Avoid fluid overload, which can precipitate pulmonary edema or ARDS 3
- Never administer steroids—they have been shown to have adverse effects in dengue 3
- Do not change management based solely on persistent fever without clinical deterioration 2
Differential Diagnosis Considerations
When evaluating rash with fever in returned travelers, also consider 1:
- Rickettsial infections (especially with tick exposure in game parks—look for eschar)
- Chikungunya (shorter incubation 2-3 days, more prominent arthralgia)
- HIV seroconversion illness
- Acute schistosomiasis (if freshwater exposure 4-8 weeks prior with eosinophilia)
Discharge Criteria
Patients can be discharged when 2:
- Afebrile for ≥48 hours without antipyretics
- Stable hemodynamic parameters for ≥24 hours
- Platelet count and hematocrit returning to normal ranges
- Adequate oral intake maintained
- Resolution or significant improvement of symptoms
Post-discharge instructions: Monitor temperature twice daily and return immediately if fever ≥38°C on two consecutive readings or any warning signs develop 2
Special Population: Pregnant Women
- Acetaminophen remains the safest analgesic option 2, 5
- Test by NAAT for both dengue and Zika viruses regardless of outbreak patterns due to possible adverse outcomes 1, 5
- Dengue infection may increase risk for maternal death, hemorrhage, preeclampsia, and vertical transmission during peripartum period 1