What is the approach to managing suspected or confirmed dengue (Dengue Fever)?

Approach to Dengue Fever Management

Manage most dengue patients symptomatically as outpatients with acetaminophen for fever/pain, ensure adequate oral hydration exceeding 2500 mL daily, and perform daily complete blood count monitoring to track hematocrit and platelet trends—hospitalize only those with warning signs or shock. 1, 2

Initial Assessment and Risk Stratification

Clinical Presentation to Recognize

• Fever with headache, retro-orbital pain, myalgia, arthralgia (particularly back pain), and rash occurring 4-8 days after mosquito exposure 3, 1
• Day-biting Aedes mosquitoes (especially Aedes aegypti) are the vectors 1, 2

Diagnostic Testing

• Days 1-7 of symptoms: Order dengue PCR/NAAT on serum 3
• After day 5-7 of symptoms: Order IgM capture ELISA if PCR unavailable or negative 3
• Note that cross-reactivity with other flaviviruses (yellow fever, Japanese encephalitis, tick-borne encephalitis) can occur, so document vaccination history 3

Critical Warning Signs Requiring Hospitalization

Monitor for these indicators of progression to severe dengue 1, 2, 4:

• Persistent vomiting or severe abdominal pain
• Mucosal bleeding (gums, nose, GI tract)
• Lethargy, restlessness, or altered mental status
• Rising hematocrit with rapidly falling platelet count (most important laboratory indicator)
• Hepatomegaly or clinical fluid accumulation (ascites, pleural effusion)

Outpatient Management (Dengue Without Warning Signs)

Symptomatic Treatment

• Acetaminophen only at standard doses for fever and pain control 1, 2
• Never use aspirin or NSAIDs due to increased bleeding risk with thrombocytopenia 3, 1, 2

Hydration Strategy

• Oral rehydration solutions with goal exceeding 2500 mL daily 1, 4
• Adequate oral intake is essential to prevent progression to shock 1

Monitoring Requirements

• Daily complete blood count to track platelet counts and hematocrit 1, 2
• Instruct patients to monitor temperature twice daily 1
• Return immediately if fever ≥38°C on two consecutive readings or any warning signs develop 1

Inpatient Management (Dengue With Warning Signs)

Admission Criteria and Initial Workup

• Hospitalize all patients with warning signs to prevent progression to dengue shock syndrome 4
• Obtain: complete blood count with hematocrit/platelets, liver function tests, coagulation profile if bleeding present 4
• The critical phase occurs days 3-7 of illness—this is when plasma leakage peaks 4

Fluid Management Protocol

For stable patients with warning signs:

• Start with oral rehydration solutions exceeding 2500 mL daily 4
• Monitor for signs of fluid overload (avoid excessive fluids in patients without shock) 2

For dengue shock syndrome (hypotension or narrow pulse pressure):

• Administer 20 mL/kg isotonic crystalloid bolus over 5-10 minutes 1, 2, 4
• Reassess immediately after bolus completion 4
• May require 2-3 rapid boluses in profound shock 5
• If unresponsive to crystalloids, switch to colloid solutions (particularly effective in severe dengue shock with pulse pressure <10 mmHg) 3, 4

Vasopressor Support

If persistent tissue hypoperfusion despite adequate fluid resuscitation 3, 1:

• Epinephrine for cold shock with hypotension 4
• Norepinephrine for warm shock with hypotension 4
• Dopamine is an alternative option 3, 1

Management of Bleeding Complications

• Do NOT give prophylactic platelet transfusions 6
• Transfuse blood products only for significant active bleeding with hemodynamic compromise 1, 4
• Monitor hemoglobin and hematocrit closely if bleeding occurs 4

Discharge Criteria

Patients can be safely discharged when ALL of the following are met 1:

• Afebrile for ≥48 hours without antipyretics
• Resolution or significant improvement of symptoms
• Stable hemodynamic parameters for ≥24 hours without support
• Adequate oral intake and urine output (>0.5 mL/kg/hour in adults)
• Laboratory parameters returning to normal ranges

Special Populations

Pregnant Women

• Test by NAAT for both dengue and Zika virus regardless of outbreak patterns due to risk of adverse outcomes 3, 2
• Acetaminophen remains the safest analgesic option 1, 2
• Dengue increases risk for maternal death, hemorrhage, preeclampsia, and vertical transmission during peripartum period 3

Children

• Calculate acetaminophen dosing carefully based on weight 1
• Same fluid management principles apply with 20 mL/kg boluses for shock 1

Critical Pitfalls to Avoid

• Never delay fluid resuscitation in patients showing signs of shock—this is the most common cause of preventable mortality 1, 2
• Never use aspirin or NSAIDs when dengue cannot be excluded 3, 1, 2
• Avoid excessive fluid boluses in patients without shock to prevent pulmonary edema and respiratory complications 2
• Do not drain pleural effusions or ascites as this can lead to severe hemorrhage and sudden circulatory collapse 5
• A 20% rise in hematocrit with continuing platelet drop is the key indicator for impending shock—act before hypotension develops 5