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

Dengue Management

Dengue management is primarily supportive with careful fluid management and acetaminophen for symptom control, as there are no specific antiviral therapies available. 1, 2

Diagnostic Confirmation

• Perform PCR or nucleic acid amplification testing on serum collected within 7 days of symptom onset for diagnostic confirmation 1, 2
• Use IgM capture ELISA for patients presenting after 5-7 days of symptoms when PCR is unavailable or negative 1, 2
• Rapid diagnostic tests combining NS1 antigen and IgG have very high positive likelihood ratios and can optimize management 3

Pain and Fever Management

• Use acetaminophen exclusively at standard doses for pain and fever relief - this is the only safe analgesic option 1, 2
• Never use aspirin or NSAIDs under any circumstances due to increased bleeding risk and platelet dysfunction 1, 2
• This prohibition applies to all dengue patients regardless of severity 2

Fluid Management for Non-Severe Dengue

• Ensure adequate oral hydration with oral rehydration solutions targeting fluid intake exceeding 2500ml daily for patients without warning signs 1, 2
• Patients without warning signs can be managed as outpatients with aggressive oral hydration 2

Monitoring Requirements

• Perform daily complete blood count to track platelet counts and hematocrit levels 1, 2
• Monitor continuously for warning signs including persistent vomiting, abdominal pain, lethargy, restlessness, mucosal bleeding, and rising hematocrit with falling platelet count 1, 4
• A hematocrit rise of 20% along with continuing platelet drop indicates impending shock 5
• Warning signs typically appear around day 3-7 of illness during defervescence 4

Management of Dengue Shock Syndrome

• Administer initial fluid bolus of 20 mL/kg isotonic crystalloid over 5-10 minutes with immediate reassessment 1, 2, 4
• Reassess immediately after bolus completion and consider additional boluses if necessary 2
• Consider colloid solutions for severe shock when pulse pressure is <10 mmHg 1, 2
• Use continuous cardiac telemetry and pulse oximetry for hemodynamic monitoring 1, 2
• For persistent tissue hypoperfusion despite adequate fluid resuscitation, use vasopressors (dopamine or epinephrine) 1

Critical Pitfalls in Shock Management

• Narrow pulse pressure (<20 mmHg) is an earlier and more sensitive indicator than absolute hypotension 4
• Avoid over-resuscitation as excessive fluids can worsen outcomes given the underlying plasma leakage pathophysiology 4
• In resource-limited settings without mechanical ventilation, aggressive fluid boluses may increase mortality, though colloids show benefit for time to resolution of shock 2

Transfusion Indications

• Blood transfusion may be necessary for significant bleeding 2
• Prophylactic platelet transfusion is not recommended 6

Discharge Criteria

• 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 2
• Return immediately if temperature rises to ≥38°C on two consecutive readings or if any warning signs develop 2

Special Populations

• Acetaminophen remains the safest analgesic option for pregnant women 1, 2
• Test pregnant women by NAAT for both dengue and Zika virus regardless of outbreak patterns due to risk of adverse outcomes 2
• Calculate acetaminophen dosing carefully based on weight for children 1

Management of Complications

• Obtain blood and urine cultures and chest radiograph if fever persists beyond 5 days to evaluate for secondary bacterial infections 2
• Patients remaining hemodynamically unstable should have management broadened to include coverage for potential secondary infections 2
• Avoid changing antibiotics based solely on persistent fever pattern without clinical deterioration or new findings 2
• Secondary hemophagocytic lymphohistiocytosis is a potentially fatal complication requiring recognition and specific management with steroids or intravenous immunoglobulin 6

Prevention Considerations

• Day-biting mosquitoes of the genus Aedes, particularly Aedes aegypti, are the primary vectors 2
• Early recognition of warning signs and appropriate management can reduce case-fatality rate to <0.5% 4