What are the indications for hospital admission in patients with dengue fever based on signs, symptoms, and laboratory findings?

Hospital Admission Indications for Dengue Fever

Hospitalize patients with dengue fever who exhibit any warning signs, including persistent vomiting, severe abdominal pain, clinical fluid accumulation, mucosal bleeding, lethargy/restlessness, liver enlargement, or laboratory evidence of rising hematocrit with rapidly decreasing platelet count. 1

Warning Signs Requiring Admission

The following clinical and laboratory findings mandate hospitalization for close monitoring during the critical phase:

Clinical Warning Signs

• Persistent vomiting that prevents adequate oral hydration 1, 2
• Severe abdominal pain or tenderness 1, 2, 3
• Clinical fluid accumulation (pleural effusion, ascites) 1, 2, 3
• Mucosal bleeding (gums, nose, gastrointestinal tract) 1, 2, 3
• Lethargy or restlessness indicating altered mental status 1, 2
• Liver enlargement (hepatomegaly >2 cm) 1, 2, 3

Laboratory Warning Signs

• Rapidly decreasing platelet count with concurrent hematocrit rise 1, 2, 3
• Rising hematocrit (>20% increase from baseline), indicating hemoconcentration and plasma leakage 4, 1, 5
• Thrombocytopenia ≤100,000/mm³, particularly when declining rapidly 4, 6

Severe Dengue Requiring Immediate Admission

Patients meeting criteria for severe dengue require immediate hospitalization and intensive monitoring:

• Severe plasma leakage leading to shock or respiratory distress from fluid accumulation 4, 1, 2
• Severe bleeding beyond mucosal bleeding (gastrointestinal hemorrhage, hematemesis) 4, 1, 6
• Organ failure (acute kidney injury, hepatic failure with ALT/AST >1000 IU/L, acute pancreatitis, encephalopathy) 4, 1, 7
• Dengue shock syndrome: hypotension or narrow pulse pressure ≤20 mmHg 4, 1, 8

Hemodynamic Instability Indicators

Admit patients showing early signs of shock:

• Narrow pulse pressure (<20 mmHg) 4, 8
• Cold, clammy extremities with delayed capillary refill 1, 8
• Tachycardia with weak pulse 8
• Hypotension for age 4, 8

High-Risk Populations Requiring Lower Threshold for Admission

• Pregnant women with confirmed or suspected dengue due to risk of maternal death, hemorrhage, preeclampsia, and vertical transmission 4, 1
• Patients with comorbidities (diabetes, hypertension, chronic kidney disease, cardiovascular disease) 1
• Infants and elderly patients who may decompensate rapidly 1

Practical Application

The presence of ANY single warning sign warrants hospitalization, as research shows that while individual warning signs have limited sensitivity (no single sign >64%), their presence indicates patients at risk for progression to severe disease. 3 However, the combination of 3-4 warning signs has >90% specificity for severe dengue. 3

Critical pitfall to avoid: Do not wait for multiple warning signs to develop before admitting. The critical phase typically occurs 3-7 days after fever onset, and plasma leakage can progress rapidly within 24-48 hours. 1, 2 Early hospitalization when the first warning sign appears allows for aggressive oral hydration, close monitoring with daily complete blood counts, and timely intervention if shock develops. 1, 5

Outpatient Management Criteria

Patients may be managed as outpatients ONLY if ALL of the following are met:

• No warning signs present 1
• Tolerating adequate oral fluids (>2500 mL daily) 1
• Platelet count >100,000/mm³ without rapid decline 4
• Stable hematocrit without evidence of hemoconcentration 1
• Reliable follow-up with ability to return immediately if warning signs develop 1
• Day 4-5 of illness has passed without complications (the typical critical phase window) 8