What is the approach to a patient with suspected dengue shock syndrome, dilated cardiomyopathy (Cardiomyopathy, Dilated), and a history of ischemic cerebrovascular (CV) stroke?

Management of Dengue Shock Syndrome in a Patient with Dilated Cardiomyopathy and Prior Ischemic Stroke

This patient requires immediate aggressive fluid resuscitation for dengue shock syndrome using isotonic crystalloids (Ringer's lactate or 0.9% saline) as first-line therapy, with extremely cautious fluid management and early consideration of colloids if shock persists, while simultaneously maintaining guideline-directed medical therapy for dilated cardiomyopathy and implementing strict hemodynamic monitoring to prevent fluid overload that could precipitate acute decompensation. 1, 2

Immediate Resuscitation Strategy for Dengue Shock Syndrome

Initial Fluid Management

• Administer 20-30 mL/kg of isotonic crystalloid (Ringer's lactate or 0.9% saline) in the first hour for initial resuscitation of dengue shock syndrome 2, 3
• Crystalloid solutions are indicated as first-line therapy for moderately severe dengue shock syndrome, with no significant difference in mortality compared to colloids 2
• If shock persists after initial crystalloid bolus, escalate to colloid therapy with 6% hydroxyethyl starch (preferred over dextran 70 due to fewer adverse reactions) at 10-15 mL/kg 2

Critical Monitoring Parameters

• Obtain baseline echocardiography immediately to assess left ventricular ejection fraction, stroke volume index (SVI), and right ventricular function 4
• Monitor pulse rate continuously—tachycardia >114 bpm predicts recurrent shock 4
• Measure venous lactate on admission—levels >4.2 mmol/L strongly predict recurrent shock and correlate with total fluid requirements 4
• Low stroke volume index (<21.6 mL/m²) on initial assessment identifies patients at highest risk for recurrent shock 4

Managing the Competing Risks: DCM and Stroke History

Fluid Balance in the Context of Dilated Cardiomyopathy

• This patient faces the dual threat of inadequate resuscitation (leading to recurrent dengue shock) versus fluid overload (precipitating acute heart failure decompensation) 4, 3
• Patients with recurrent shock receive significantly more total IV fluids and have higher rates of respiratory distress 4
• Total IV fluid volume directly correlates with respiratory distress (OR 1.03 per mL/kg, 95% CI 1.01-1.06) 4

Active Fluid Removal Strategy

• Implement early and aggressive fluid removal once shock resolves—this approach decreased mortality from 16.6% to 6.3% in dengue shock syndrome 3
• Use furosemide or other diuretics to actively remove fluid as soon as hemodynamic stability is achieved (typically within 24-48 hours) 3
• Monitor for signs of fluid overload: increasing respiratory rate, oxygen desaturation, pulmonary crackles, and worsening left ventricular myocardial performance index on serial echocardiography 4

Hemodynamic Monitoring Requirements

• Place pulmonary artery catheter for invasive hemodynamic monitoring—this is standard of care in cardiogenic shock and will be invaluable in this complex patient 5
• Target cardiac index >2.2 L/min/m² and pulmonary capillary wedge pressure 15-18 mmHg to balance adequate perfusion against pulmonary edema 5
• Perform daily portable echocardiography for 5 days to assess stroke volume index, left ventricular function, and intravascular volume status 4

Maintaining Cardiac Medications During Acute Illness

Guideline-Directed Medical Therapy Continuation

• Continue ACE inhibitors/ARBs and beta-blockers at current doses unless hypotension (SBP <90 mmHg) or shock necessitates temporary discontinuation 6, 7
• If vasopressors are required for persistent shock, use norepinephrine as first-line agent to maintain mean arterial pressure >65 mmHg 5
• Avoid inotropes (dobutamine, milrinone) unless cardiac index remains <2.2 L/min/m² despite adequate preload, as these increase myocardial oxygen demand and arrhythmia risk 5

Mineralocorticoid Receptor Antagonist Management

• Temporarily hold spironolactone or eplerenone during acute phase due to risk of hyperkalemia with acute kidney injury and potential hemodynamic instability 6
• Resume once patient is stabilized and potassium <5.0 mEq/L 7

Stroke Prevention During Acute Illness

Anticoagulation Considerations

• Dengue hemorrhagic fever causes severe thrombocytopenia and coagulopathy—platelet counts in dengue shock syndrome average 36-42 × 10⁹/L 2
• Hold all anticoagulation (warfarin, DOACs) and antiplatelet agents during acute dengue illness due to high bleeding risk 2
• Monitor for bleeding manifestations: petechiae, ecchymoses, gastrointestinal bleeding, and intracranial hemorrhage 2
• Resume anticoagulation only after platelet count recovers to >50 × 10⁹/L and coagulation parameters normalize (typically 5-7 days after defervescence)

Blood Pressure Management

• Maintain systolic blood pressure 120-140 mmHg to balance stroke prevention against adequate perfusion during shock 5
• Avoid excessive hypertension during fluid resuscitation, which could increase risk of recurrent stroke in this patient with prior ischemic cerebrovascular disease

Risk Stratification for Sudden Cardiac Death

ICD Considerations

• If LVEF <35% on optimal medical therapy, this patient requires ICD for primary prevention of sudden cardiac death 5, 6
• Defer ICD implantation until after complete recovery from dengue shock syndrome and reassessment of LVEF at 3-6 months 7
• Mid-wall fibrosis on cardiac MRI is the strongest independent predictor of sudden cardiac death in DCM and should be assessed once acute illness resolves 5

Arrhythmia Monitoring

• Continuous telemetry monitoring is mandatory—ventricular arrhythmias occur in 20-70% of DCM patients depending on symptom severity 5
• Syncope history in DCM patients carries 70% risk of sustained ventricular tachycardia or sudden cardiac death 5

Prognostic Indicators and Expected Course

Poor Prognostic Factors in This Patient

• Admission lactate >4.2 mmol/L predicts recurrent shock 4
• Stroke volume index <21.6 mL/m² predicts recurrent shock requiring additional fluid resuscitation 4
• Severe LV dysfunction, RV dysfunction, and moderate-to-severe mitral regurgitation are poor prognostic indicators in DCM 6

Expected Timeline

• Dengue shock syndrome typically resolves within 24-48 hours with appropriate fluid management 1, 2
• Plasma leakage phase lasts 24-48 hours, followed by reabsorption phase where aggressive diuresis is critical 3
• Mortality in dengue shock syndrome with aggressive protocol management is <1% 2, 3

Common Pitfalls to Avoid

• Do not under-resuscitate due to fear of fluid overload—inadequate initial resuscitation leads to recurrent shock, which ultimately requires more total fluid and increases respiratory distress risk 4, 3
• Do not continue aggressive fluid administration beyond 48 hours—failure to actively remove fluid after shock resolution is associated with higher mortality 3
• Do not use dextran 70 despite its rapid hematocrit normalization—it causes significantly more adverse reactions than hydroxyethyl starch 2
• Do not restart anticoagulation prematurely—bleeding complications in dengue are common and potentially fatal 2
• Do not discontinue beta-blockers abruptly unless absolutely necessary for hemodynamic support, as this increases arrhythmia and sudden death risk in DCM 5, 6