Pulse Steroids and IVIG in Dengue: Current Evidence Does Not Support Routine Use
Based on the available evidence, pulse steroids and IVIG should NOT be used routinely in dengue management, as high-quality studies show no mortality benefit and potential harm. However, these therapies may be considered as salvage/rescue therapy in highly selected cases of refractory dengue shock syndrome or secondary hemophagocytic lymphohistiocytosis (HLH) when standard fluid resuscitation has failed.
Evidence Against Routine Use
Pulse Steroids - No Proven Benefit
- A randomized, double-blind, placebo-controlled trial of methylprednisolone (30 mg/kg single dose) in 63 children with severe dengue shock syndrome showed no reduction in mortality (12.5% vs 12.9%, p=0.63) compared to placebo 1
- The steroid group had no difference in bleeding severity, liver failure, disseminated intravascular coagulation, or other complications compared to controls 1
- A comprehensive review concluded there is no high-quality evidence supporting corticosteroids for treatment of shock, prevention of complications, or increasing platelet counts in dengue 2
IVIG - Limited Evidence
- Trials of IVIG in dengue have not shown significant benefit in terms of survival or improvement in clinical parameters 3
- The evidence base for IVIG in dengue is very limited, with well-designed randomized controlled trials lacking 3
When to Consider as Rescue Therapy
Refractory Dengue Shock Syndrome
- Consider pulse methylprednisolone or IVIG only when standard fluid resuscitation and plasma replacement have failed and the patient remains in refractory shock 2, 4
- Non-randomized trials suggest possible benefit when used as rescue medication for severe refractory shock, though evidence quality is poor 2
- In one retrospective series, IVIG (0.4 g/kg for 5 days) was used in 13 critically ill patients with complicated dengue where standard therapy failed, with 2 deaths among 13 patients (15% mortality) 4
Secondary Hemophagocytic Lymphohistiocytosis (HLH)
- HLH complicating dengue is a specific indication where steroids or IVIG may improve outcomes 5
- This is a potentially fatal complication that requires recognition and specific immunomodulatory management 5
- In the retrospective IVIG series, 2 patients with HLH secondary to dengue received IVIG as rescue therapy 4
Practical Algorithm for Decision-Making
Step 1: Optimize Standard Management First
- Judicious fluid resuscitation with crystalloids is the cornerstone of dengue management 5
- Ensure adequate plasma replacement therapy has been attempted in shock 1
- Monitor for organ involvement (liver failure, acute kidney injury, ARDS, myocarditis) 4
Step 2: Identify Refractory Cases
- Define refractory shock as persistent hypotension despite adequate fluid resuscitation (20-40 mL/kg crystalloids + plasma replacement) 2, 4
- Look for signs of HLH: persistent fever, hepatosplenomegaly, cytopenias, hyperferritinemia, hypertriglyceridemia 5
Step 3: Consider Rescue Therapy
- For refractory shock without HLH: Consider pulse methylprednisolone 30 mg/kg as a single dose OR IVIG 0.4 g/kg/day for 5 days 4, 1
- For suspected/confirmed HLH: Strongly consider steroids or IVIG as specific management 5
- Document that standard therapy has failed before initiating rescue immunomodulation 2, 4
Critical Caveats
Timing Matters
- Do not use steroids or IVIG as first-line therapy or prophylactically 2, 1
- These should only be considered after standard fluid management has demonstrably failed 2, 4
Monitoring Requirements
- If rescue therapy is used, closely monitor for complications including secondary infections, hyperglycemia, and bleeding 1
- The mortality rate in refractory dengue shock remains high (15-44%) even with rescue therapy 4
Cost and Availability
- IVIG is expensive and may not be readily available in dengue-endemic regions 3
- The cost-benefit ratio is unfavorable given the lack of proven efficacy 3