What is the treatment for dengue fever?

Treatment of Dengue Fever

Dengue fever treatment is entirely supportive and symptomatic, as no specific antiviral therapy exists—focus on adequate hydration, acetaminophen for pain/fever, strict avoidance of aspirin/NSAIDs, and careful monitoring for progression to severe disease. 1, 2

General Management Principles

• Symptomatic management is the cornerstone of treatment since no approved antiviral therapy is currently available 2, 3
• More than 90% of dengue cases follow a mild course and can be managed as outpatients with oral hydration 3
• The disease follows a characteristic triphasic pattern: febrile phase, critical phase (days 3-7), and recovery phase—the critical phase is when plasma leakage and shock can rapidly develop 1, 3

Pain and Fever Management

• Acetaminophen (paracetamol) is the only recommended analgesic, dosed at 10-15 mg/kg every 4-6 hours, not exceeding 4 g/day in adults 4
• Never use aspirin or NSAIDs under any circumstances due to significantly increased bleeding risk from platelet dysfunction and potential hemorrhagic complications 1, 2, 4
• Monitor liver function tests when using acetaminophen, particularly in patients with pre-existing liver disease, as dengue itself causes hepatic involvement 4, 5

Fluid Management Strategy

For Patients Without Shock:

• Ensure adequate oral hydration with a target of >2,500-3,000 mL daily using any locally available fluids including water, oral rehydration solutions, cereal-based gruels, soup, and rice water 1, 2
• Avoid soft drinks due to high osmolality 2
• Do not administer routine bolus intravenous fluids in patients with severe febrile illness who are NOT in shock, as this increases risk of fluid overload and respiratory complications without improving outcomes 2

For Dengue Shock Syndrome:

• Administer 20 mL/kg of isotonic crystalloid (Ringer's lactate or 0.9% normal saline) as a rapid bolus over 5-10 minutes 1, 2
• Reassess immediately after each bolus for signs of improvement (reduced tachycardia, improved capillary refill, warming of extremities, improved mental status) 2
• Repeat crystalloid boluses up to a total of 40-60 mL/kg in the first hour if shock persists 2
• Consider colloid solutions (dextran, gelafundin, or albumin) for severe shock with pulse pressure <10 mmHg, as moderate-quality evidence shows colloids achieve faster resolution of shock (RR 1.09,95% CI 1.00-1.19) and reduce total volume needed (31.7 mL/kg versus 40.63 mL/kg for crystalloids) 2

For Refractory Shock:

• If shock persists despite adequate fluid resuscitation (40-60 mL/kg), initiate vasopressors immediately—delays in vasopressor therapy significantly increase mortality 2
• For cold shock with hypotension: use epinephrine as first-line vasopressor 2
• For warm shock with hypotension: use norepinephrine as first-line vasopressor 2
• Target mean arterial pressure appropriate for age and maintain ScvO2 >70% 2

Critical Monitoring Parameters

• Daily complete blood count is essential to track platelet counts and hematocrit levels—rising hematocrit with rapidly falling platelets signals impending shock 1, 2
• Monitor for warning signs of severe dengue: persistent vomiting, severe abdominal pain, lethargy or restlessness, mucosal bleeding, hepatomegaly, and fluid accumulation (pleural effusion, ascites) 1, 2
• Watch for clinical indicators of adequate tissue perfusion: normal capillary refill time (<2 seconds), absence of skin mottling, warm and dry extremities, well-felt peripheral pulses, return to baseline mental status, and adequate urine output (>0.5 mL/kg/hour in adults) 2
• Stop fluid resuscitation immediately if hepatomegaly or pulmonary rales develop—these signal fluid overload requiring switch to inotropic support 2

Management of Bleeding Complications

• Blood transfusion may be necessary for significant bleeding, though platelet transfusions have little role in routine management 2, 6
• Massive hematemesis may occur in adults due to peptic ulcer disease and may not be associated with profound shock as seen in children 5
• Internal hemorrhage frequency rises with increasing age, while shock and plasma leakage are more prevalent in younger patients 5

Diagnostic Confirmation

• Order dengue PCR/NAAT on serum for patients with symptoms for 1-7 days (up to day 5 is optimal) 1, 3
• Order IgM capture ELISA if PCR is unavailable or negative for patients with symptoms for more than 5-7 days 1
• For pregnant women or patients with possible Zika exposure, perform NAAT for both dengue and Zika virus regardless of outbreak patterns 1

Discharge Criteria

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

• Afebrile for ≥48 hours without antipyretics 1
• Resolution or significant improvement of symptoms 1
• Stable hemodynamic parameters for ≥24 hours without support (normal heart rate, stable blood pressure, normal capillary refill) 1
• Adequate oral intake and urine output (>0.5 mL/kg/hour in adults) 1
• Laboratory parameters returning to normal ranges 1

Post-Discharge Instructions

• Monitor and record temperature twice daily 1
• Return immediately if temperature rises to ≥38°C on two consecutive readings or if any warning signs develop (persistent vomiting, severe abdominal pain, bleeding, lethargy) 1

Special Populations

• For pregnant women: acetaminophen remains the safest analgesic option, and testing by NAAT for both dengue and Zika virus is mandatory due to risk of adverse outcomes 1, 4
• In children: calculate acetaminophen dosing carefully based on weight (10-15 mg/kg per dose) 4
• Adults with pre-existing liver diseases (chronic hepatitis, alcoholic cirrhosis) or hemoglobinopathies may experience aggravated liver impairment—fulminant hepatitis is rare but well-described 5

Critical Pitfalls to Avoid

• Never delay fluid resuscitation in established dengue shock syndrome—once hypotension occurs, cardiovascular collapse may rapidly follow, and delays significantly increase mortality 2
• Do not fail to recognize the critical phase (days 3-7) when plasma leakage can rapidly progress to shock—this is when most deaths occur 1
• Do not continue aggressive fluid resuscitation once signs of fluid overload appear (hepatomegaly, rales, respiratory distress)—switch to inotropic support instead 2
• Do not administer excessive fluid boluses in patients without shock, as this leads to fluid overload and respiratory complications 2
• Restrictive fluid strategies have no survival benefit in dengue shock syndrome and may worsen outcomes—three RCTs demonstrate near 100% survival with aggressive fluid management 2