What is the treatment for Dengue (Dengue Fever)?

Treatment of Dengue Fever

There is no specific antiviral therapy for dengue; treatment is entirely supportive, centered on aggressive fluid management to prevent progression to shock, acetaminophen for symptom control, and strict avoidance of aspirin and NSAIDs due to bleeding risk. 1, 2, 3

Risk Stratification and Triage

Dengue must be classified into three categories that determine management intensity 1, 4:

• Dengue without warning signs: Outpatient management with oral hydration and daily monitoring 4
• Dengue with warning signs: Hospitalization required with intensive monitoring during the critical phase (days 3-7 of illness) 5
• Severe dengue: ICU admission for dengue shock syndrome, severe bleeding, or organ impairment 1

Warning signs that mandate hospitalization include: severe abdominal pain, persistent vomiting, mucosal bleeding, lethargy or restlessness, rising hematocrit with rapidly falling platelet count, hepatomegaly, and clinical fluid accumulation 1, 5

Fluid Management Strategy

For Patients Without Shock

• Oral rehydration is the cornerstone of treatment, targeting >2,500-3,000 mL daily using any locally available fluids including water, oral rehydration solutions, cereal-based gruels, soup, and rice water 1
• Avoid soft drinks due to high osmolality 1
• Critical pitfall: Do NOT administer routine bolus IV fluids to patients with severe febrile illness who are not in shock, as this increases risk of fluid overload and respiratory complications without improving outcomes 1

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, 5:

• Repeat crystalloid boluses up to a total of 40-60 mL/kg in the first hour if shock persists 1
• Colloid solutions (gelafundin, albumin, or dextran) achieve faster resolution of shock (RR 1.09,95% CI 1.00-1.19) and require less total volume (mean 31.7 mL/kg versus 40.63 mL/kg for crystalloids) 1
• Consider colloids for severe shock with pulse pressure <10 mmHg 1

Stop fluid resuscitation immediately if signs of fluid overload develop: hepatomegaly, pulmonary rales, or respiratory distress 1. Switch to inotropic support instead of continuing aggressive fluids 1.

Vasopressor Management for Refractory Shock

If shock persists despite adequate fluid resuscitation 1:

• Cold shock with hypotension: Titrate epinephrine as first-line vasopressor
• Warm shock with hypotension: Titrate norepinephrine as first-line vasopressor
• Begin peripheral inotropic support immediately if central venous access is not readily available, as delays in vasopressor therapy are associated with major increases in mortality 1

Symptomatic Management

• Acetaminophen (paracetamol) at standard doses is the ONLY acceptable analgesic for pain and fever control 1, 4, 5
• Never use aspirin or NSAIDs under any circumstances due to increased bleeding risk and platelet dysfunction 6, 1, 4, 7

Monitoring Parameters

Daily complete blood count monitoring is essential to track platelet counts and hematocrit levels 1, 4:

• Watch for high hematocrit with rapidly falling platelet count 1
• Monitor for clinical indicators of adequate tissue perfusion: normal capillary refill time, absence of skin mottling, warm and dry extremities, well-felt peripheral pulses, return to baseline mental status, and adequate urine output 1

The critical phase typically occurs on days 3-7 of illness when plasma leakage can rapidly progress to shock 1. Failure to recognize this phase is a common pitfall 1.

Management of Bleeding Complications

• Blood transfusion may be necessary in cases of significant bleeding 1, 4
• Prophylactic platelet transfusion is not recommended 8
• Major bleeding almost invariably occurs in combination with profound shock, thrombocytopenia, hypoxia, and acidosis 9

Discharge Criteria

Patients can be safely discharged when ALL of the following are met 4, 5:

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

Post-discharge instructions: Monitor temperature twice daily and return immediately if temperature rises to ≥38°C on two consecutive readings or if any warning signs develop 4.

Key Clinical Pitfalls to Avoid

• Delaying fluid resuscitation in established dengue shock syndrome significantly increases mortality; once hypotension occurs, cardiovascular collapse may rapidly follow 1
• Overhydration during the recovery phase can lead to pulmonary edema 1
• Failing to recognize the critical phase (days 3-7) when plasma leakage accelerates 1
• Changing management based solely on persistent fever without clinical deterioration or new findings 4