What is the management approach for dengue (Dengue fever)?

Dengue Management

Immediate Diagnostic Approach

For suspected dengue, perform PCR/nucleic acid amplification testing on serum collected within 7 days of symptom onset, or use IgM capture ELISA if symptoms have been present for more than 5-7 days. 1, 2

• Dengue presents with fever, headache, retro-orbital pain, myalgia, arthralgia, and rash occurring 4-8 days after mosquito exposure 2
• NS1 antigen detection is useful from day 1 to day 10 after symptom onset 3
• Document vaccination history to avoid cross-reactivity with other flaviviruses (yellow fever, Japanese encephalitis, tick-borne encephalitis) 2
• For pregnant women, test by NAAT for both dengue and Zika virus regardless of outbreak patterns due to risk of adverse outcomes 2

Pain and Fever Management

Use acetaminophen at standard doses exclusively for pain and fever relief; never use aspirin or NSAIDs due to increased bleeding risk and platelet dysfunction. 1, 2

• Acetaminophen remains the safest analgesic option for pregnant women and children (dose carefully calculated by weight) 1, 2
• This is a critical pitfall to avoid—aspirin and NSAIDs are absolutely contraindicated when dengue cannot be excluded 2

Fluid Management for Non-Severe Dengue

Ensure adequate oral hydration with oral rehydration solutions targeting fluid intake exceeding 2500ml daily for non-severe dengue cases. 1, 2

• Use oral rehydration solutions for moderate dehydration 1
• This approach is appropriate for dengue without warning signs 2

Recognition of Warning Signs Requiring Hospitalization

Monitor continuously for warning signs that indicate potential progression to severe dengue: persistent vomiting, abdominal pain/tenderness, clinical fluid accumulation, mucosal bleeding, lethargy/restlessness, hepatomegaly, and rising hematocrit with falling platelet count. 1, 3

• Warning signs typically appear around day 3-7 of illness, coinciding with defervescence 3
• Presence of any warning sign warrants close monitoring and consideration for hospitalization 3
• A rise in hematocrit of 20% along with continuing drop in platelet count is an important indicator for onset of shock 4
• Early recognition and appropriate management can reduce case-fatality rate to <0.5% 3

Laboratory Monitoring

Perform daily complete blood count to track platelet counts and hematocrit levels throughout the illness. 1, 2

• Frequent hematocrit determinations are essential for evaluating treatment response 4
• Thrombocytopenia with concurrent hemoconcentration differentiates dengue hemorrhagic fever from classical dengue fever 4

Management of Dengue Shock Syndrome

For dengue shock syndrome, administer an initial fluid bolus of 20 mL/kg isotonic crystalloid over 5-10 minutes with immediate reassessment afterward. 1, 2, 3

• Reassess immediately after bolus completion and consider additional boluses if necessary—as many as 2-3 boluses may be needed in profound shock 2, 4
• Consider colloid solutions for severe shock when available, particularly when pulse pressure is <10 mmHg 1, 2
• Colloids show benefit for time to resolution of shock compared to crystalloids alone 2
• The ideal fluid management includes both crystalloids and colloids (including albumin) 4

Recognizing Dengue Shock Syndrome

Dengue shock syndrome is defined by:

• Systolic blood pressure <90 mmHg for >30 minutes 3
• Pulse pressure <20 mmHg persisting despite initial fluid resuscitation 3
• Signs of end-organ hypoperfusion: cold clammy extremities, livedo reticularis, capillary refill time ≥3 seconds, elevated lactate >2 mmol/L 3

Note that narrow pulse pressure (<20 mmHg) is an earlier and more sensitive indicator of dengue shock than absolute hypotension. 3

Critical Care Monitoring for Shock

• Use continuous cardiac telemetry and pulse oximetry for dengue shock syndrome 1, 2
• Oxygen is mandatory in all patients with shock 4
• Avoid over-resuscitation as excessive fluids can worsen outcomes given the underlying plasma leakage pathophysiology 3

Management of Complications

For persistent tissue hypoperfusion despite adequate fluid resuscitation, use vasopressors (dopamine or epinephrine). 1

• For significant bleeding, blood transfusion may be necessary 2
• Some patients develop DIC and need supportive therapy with blood products (blood, FFP, and platelet transfusions) 4
• Prophylactic platelet transfusion is not recommended 5
• Polyserositis (pleural effusion and ascites) is common in dengue shock syndrome; avoid drainage if possible as it can lead to severe hemorrhages and sudden circulatory collapse 4

Management of Persistent Fever

Persistent fever is common in dengue and typically resolves within 5 days of treatment initiation. 2

• Obtain blood and urine cultures and chest radiograph if fever persists to diagnose secondary bacterial infections 2
• Patients who remain hemodynamically unstable should have management broadened to include coverage for potential secondary infections 2
• Avoid changing antibiotics or management based solely on persistent fever pattern without clinical deterioration or new findings 2

Discharge Criteria

Patients can be safely discharged when all of the following criteria are met: 1, 2

• Afebrile for at least 48 hours without antipyretics 1, 2
• Resolution or significant improvement of symptoms 1, 2
• Laboratory parameters returning to normal ranges 1, 2
• Stable hemodynamic parameters for at least 24 hours without support 1, 2
• Adequate urine output (>0.5 mL/kg/hour in adults) 1, 2

Post-Discharge Instructions

• Monitor and record temperature twice daily after discharge 2
• Return to healthcare facility if temperature rises to ≥38°C on two consecutive readings or if any warning signs develop 2

Critical Pitfalls to Avoid

The 2007 Puerto Rico dengue epidemic revealed fatal management errors that must be avoided 6:

• Failure to recognize warning signs for severe dengue and shock 6
• Prolonged emergency department stays before inpatient admission (mean 15 hours in fatal cases) 6
• Infrequent patient monitoring, particularly during weekends 6
• Use of non-isotonic saline while in shock 6
• Administration of methylprednisolone (5 of 9 hospitalized fatal cases received this) 6
• Delaying fluid resuscitation in patients showing signs of shock 2

Current State of Antiviral Therapy

There are no effective vaccines or licensed antivirals for dengue; management remains primarily supportive with fluids. 7, 5, 8

• Several compounds with anti-dengue potential are being studied, but no anti-dengue drug is available 5
• Direct antiviral therapies would need to inhibit all four viral serotypes effectively 7