What are the latest guidelines for managing dengue (Dengue Virus Infection)?

Latest Dengue Management Guidelines

Clinical Presentation and Diagnosis

Dengue presents with fever, headache, retro-orbital pain, myalgia, arthralgia, and rash occurring 4-8 days after mosquito exposure, with a clinical spectrum ranging from mild febrile illness to life-threatening dengue hemorrhagic fever (DHF) or dengue shock syndrome (DSS). 1, 2

Diagnostic Testing Strategy

• Order dengue PCR/NAAT on serum for patients with symptoms present for 1-7 days from onset 1
• Order IgM capture ELISA if PCR is unavailable or negative, particularly for patients with symptoms for more than 5-7 days 1, 2
• For pregnant women, test by NAAT for both dengue and Zika virus regardless of outbreak patterns due to risk of adverse outcomes 1
• Document vaccination history to avoid cross-reactivity with other flaviviruses (yellow fever, Japanese encephalitis, tick-borne encephalitis) 1

Monitoring Requirements

Daily complete blood count monitoring is essential to track platelet counts and hematocrit levels, particularly during the critical phase (typically days 3-7 of illness) when plasma leakage can rapidly progress to shock. 1, 2, 3

Warning Signs Requiring Intensive Monitoring

• Persistent vomiting and severe abdominal pain 1, 2
• High hematocrit with rapidly falling platelet count 3
• Lethargy or restlessness 1
• Mucosal bleeding 1
• Rising hematocrit with falling platelet count 1

Fluid Management

For Patients WITHOUT Shock

Ensure adequate oral hydration with more than 2,500-3,000 mL daily using any locally available fluids including water, oral rehydration solutions, cereal-based gruels, soup, and rice water—avoid soft drinks due to high osmolality. 1, 2, 3

• CRITICAL PITFALL: Avoid routine bolus IV 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 3

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, with immediate reassessment after each bolus. 1, 2, 3

• If shock persists after initial bolus, repeat crystalloid boluses up to a total of 40-60 mL/kg in the first hour before escalating therapy 3
• For severe dengue shock with pulse pressure <10 mmHg or refractory shock, consider colloid solutions (dextran, gelafundin, or albumin)—moderate-quality evidence shows colloids achieve faster resolution of shock (RR 1.09,95% CI 1.00-1.19) and reduce total volume needed (mean 31.7 mL/kg versus 40.63 mL/kg for crystalloids) 3

Critical Monitoring During Resuscitation

• Watch for signs of fluid overload: hepatomegaly, rales on lung examination, or respiratory distress 3
• Stop fluid resuscitation immediately if hepatomegaly or pulmonary rales develop and switch to inotropic support instead 3
• Monitor for improvement in tachycardia, tachypnea, capillary refill time, 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) 1, 3

Pain and Fever Management

Acetaminophen at standard doses is the ONLY recommended analgesic for pain and fever relief—never use aspirin or NSAIDs under any circumstances due to high bleeding risk. 1, 2, 3

• In children, acetaminophen dosing should be carefully calculated based on weight 2
• For pregnant women, acetaminophen remains the safest analgesic option 1, 2

Management of Refractory Shock

For persistent tissue hypoperfusion despite adequate fluid resuscitation (40-60 mL/kg), initiate vasopressors immediately—delays in vasopressor therapy are associated with major increases in mortality. 1, 2, 3

Vasopressor Selection Based on Hemodynamic State

• For cold shock with hypotension: titrate epinephrine as first-line vasopressor 3
• For warm shock with hypotension: titrate norepinephrine as first-line vasopressor 3
• Begin peripheral inotropic support immediately if central venous access is not readily available 3
• Target mean arterial pressure appropriate for age and maintain ScvO2 >70% 3

Management of Bleeding Complications

• Blood transfusion may be necessary in cases of significant bleeding 1, 2, 3
• Prophylactic platelet transfusion is NOT recommended 4
• Major bleeding almost invariably occurs in combination with profound shock, thrombocytopenia, hypoxia, and acidosis 5

Respiratory Support

• For patients with respiratory distress and/or persistent hypoxemia despite oxygen therapy, consider non-invasive ventilation if available and staff is adequately trained 2
• If intubation is necessary, ketamine with atropine premedication is suggested for sedation to maintain cardiovascular stability 2

Discharge Criteria

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

• 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 time) 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 to healthcare facility if temperature rises to ≥38°C on two consecutive readings or if any warning signs develop 1

Critical Pitfalls to Avoid

• Never delay fluid resuscitation in patients showing signs of dengue shock syndrome—once hypotension occurs, cardiovascular collapse may rapidly follow 3
• Do not continue aggressive fluid resuscitation once signs of fluid overload appear 3
• 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 3
• Failing to recognize the critical phase (typically days 3-7 of illness) when plasma leakage can rapidly progress to shock 3
• Do not change antibiotics or management based solely on persistent fever pattern without clinical deterioration or new findings 1

Special Considerations

• Secondary hemophagocytic lymphohistiocytosis is a potentially fatal complication that needs recognition, as specific management with steroids or intravenous immunoglobulin may improve outcomes 4
• Obtain blood and urine cultures and chest radiograph if fever persists to diagnose secondary bacterial infections 1
• There is currently no specific antiviral therapy approved for dengue—management remains entirely supportive 6, 4, 7