Management of Dengue Encephalitis
Dengue encephalitis requires immediate supportive care with no specific antiviral therapy available; management focuses on aggressive monitoring for cerebral edema, seizure control, judicious fluid resuscitation with crystalloids, correction of coagulopathy, and early recognition of neurological deterioration which can progress rapidly to death within 2-5 days. 1, 2
Immediate Recognition and Admission
- Suspect dengue encephalitis in endemic areas when patients present with fever, altered mental status, seizures, and neurological deterioration, particularly during the convalescent phase of dengue infection 1, 3, 4
- Patients require immediate hospitalization with access to intensive care for airway protection, ventilatory support, and management of increased intracranial pressure 5
- High index of suspicion is critical as symptoms can be misinterpreted as fever delirium or toxic encephalopathy 3
- Neurological deterioration can be extremely rapid, with cerebral death occurring between 2-5 days after admission 1
Diagnostic Evaluation
- Perform NS1 antigen testing in both serum and cerebrospinal fluid for diagnosis 1
- RT-PCR should be performed to confirm dengue virus as the causative agent of encephalitis 1
- Obtain urgent neuroimaging (MRI preferred, CT if unavailable) to assess for cerebral edema and intracranial hemorrhage 5, 3
- Monitor for thrombocytopenia and deranged prothrombin time, which are common complications 3
- Lumbar puncture should be performed unless contraindicated by increased intracranial pressure 5
Supportive Management (No Specific Antiviral Therapy)
Unlike herpes simplex encephalitis, there is no specific antiviral treatment for dengue encephalitis 2. Management is entirely supportive:
Fluid Management
- Judicious fluid resuscitation with crystalloids is the cornerstone of management during the critical phase 2
- Avoid non-isotonic saline, particularly in patients with shock 4
- Over-aggressive fluid administration can worsen cerebral edema
Hematologic Management
- Correct thrombocytopenia with platelet concentrates when indicated 3
- Prophylactic platelet transfusion is NOT recommended 2
- Correct coagulopathy (deranged PT) before any invasive procedures 3
Neurological Management
- Aggressive management of increased intracranial pressure with cerebral decongestants 3
- Control seizures promptly, including focal status epilepticus (epilepsia partialis continua) which can occur 6
- Continuous neurological monitoring is essential as deterioration can be rapid 1, 3
Surgical Intervention
- Consider neurosurgical evacuation for accessible intracranial hemorrhages with neurological deterioration 3
- Patients with deep-seated bleeds have very poor prognosis with rapid deterioration 3
- Two patients who underwent timely surgery for intracranial hemorrhage had excellent outcomes 3
Critical Management Pitfalls to Avoid
Common errors that contributed to dengue deaths include: 4
- Failure to recognize warning signs for severe dengue and shock
- Prolonged emergency department stays before inpatient admission (mean 15 hours in fatal cases)
- Infrequent patient monitoring, particularly during weekends
- Use of corticosteroids (methylprednisolone) in shock, which is not indicated 4
- Misdiagnosis as simple fever delirium rather than encephalitis 3
Specialist Consultation and Multidisciplinary Care
- Obtain neurological specialist opinion within 24 hours of admission 5
- Involve infectious disease specialists, neurologists, and intensive care teams 5
- Consider transfer to specialized neuroscience center if diagnosis unclear or patient not improving 5
Emerging Therapies Under Investigation
- Secondary hemophagocytic lymphohistiocytosis is a potentially fatal complication that may respond to steroids or intravenous immunoglobulin 2
- Several compounds with anti-dengue potential are being studied, but no anti-dengue drug is currently available 2