What is the treatment for Dengue (Dengue Fever)?

Treatment of Dengue Fever

There is no specific antiviral therapy for dengue; treatment is entirely supportive with careful fluid management, acetaminophen for symptom control, and close monitoring for progression to severe disease. 1, 2

General Management Principles

Symptomatic management is the cornerstone of dengue treatment since no approved antiviral therapy exists. 1 The clinical approach depends on disease severity classification: dengue without warning signs, dengue with warning signs, and severe dengue (including dengue shock syndrome). 3, 4

Key Monitoring Requirements

• Daily complete blood count monitoring is essential to track platelet counts and hematocrit levels, particularly during the critical phase (days 3-7 of illness) when plasma leakage can rapidly progress to shock. 1, 3
• Watch for warning signs of progression: severe abdominal pain, persistent vomiting, mucosal bleeding, lethargy/restlessness, rising hematocrit with rapidly falling platelet count, and hepatomegaly. 1, 4
• Monitor clinical indicators of adequate tissue perfusion: normal capillary refill time, warm and dry extremities, well-felt peripheral pulses, return to baseline mental status, and adequate urine output (>0.5 mL/kg/hour in adults). 1

Pain and Fever Management

Use acetaminophen (paracetamol) at standard doses as the ONLY acceptable analgesic. 1, 3, 4

Absolutely avoid aspirin and NSAIDs under any circumstances due to increased bleeding risk from platelet dysfunction and potential for hemorrhagic complications. 1, 3, 5 This is a critical safety measure given dengue's hemorrhagic potential.

Fluid Management Strategy

For Dengue Without Warning Signs (Outpatient Management)

• Aggressive oral hydration is the primary intervention, aiming for more than 2,500-3,000 mL daily using any locally available fluids including water, oral rehydration solutions, cereal-based gruels, soup, and rice water. 1, 3
• Avoid soft drinks due to high osmolality. 1
• A practical approach: encourage 5 or more glasses of fluid throughout the day. 1

For Dengue With Warning Signs (Hospitalization Required)

• Hospitalize immediately for close observation during the critical phase. 4
• Oral rehydration remains the cornerstone for stable patients, exceeding 2,500 mL daily with oral rehydration solutions. 4
• If shock develops, escalate immediately to intravenous fluid resuscitation (see below). 4

For Dengue Shock Syndrome (Aggressive Resuscitation)

Administer 20 mL/kg of isotonic crystalloid (Ringer's lactate or 0.9% normal saline) as a rapid bolus over 5-10 minutes. 1, 3, 4 This is the critical first step.

Reassess immediately after each bolus for signs of improvement: decreased tachycardia, decreased tachypnea, improved capillary refill, and stabilizing blood pressure. 1

If shock persists after the initial bolus, repeat crystalloid boluses up to a total of 40-60 mL/kg in the first hour before escalating therapy. 1

For severe dengue shock (pulse pressure <10 mmHg) or refractory shock, consider colloid solutions (gelafundin, albumin, or dextran if available), which 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, 4

Management of Refractory Shock

If shock persists despite adequate fluid resuscitation:

• For cold shock with hypotension: titrate epinephrine as first-line vasopressor. 1, 4
• For warm shock with hypotension: titrate norepinephrine as first-line vasopressor. 1
• Target mean arterial pressure appropriate for age and maintain ScvO2 >70%. 1
• Begin peripheral inotropic support immediately if central venous access is not readily available, as delays in vasopressor therapy significantly increase mortality. 1

Management of Bleeding Complications

Blood transfusion may be necessary in cases of significant bleeding, particularly when combined with profound shock, thrombocytopenia, hypoxia, and acidosis. 1, 3, 6

Prophylactic platelet transfusion is NOT recommended in the absence of active bleeding. 7

Critical Pitfalls to Avoid

Do NOT administer routine bolus IV fluids in patients with severe febrile illness who are NOT in shock. 1 This increases risk of fluid overload and respiratory complications without improving outcomes—a common and dangerous error.

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

Do NOT delay fluid resuscitation once hypotension occurs, as cardiovascular collapse may rapidly follow. 1 Near 100% survival is achievable with appropriate aggressive fluid management in dengue shock syndrome.

Avoid overhydration during the recovery phase, which can lead to pulmonary edema. 1

Never fail to recognize the critical phase (days 3-7 of illness) when plasma leakage can rapidly progress to shock. 1

Discharge Criteria

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

• Afebrile for ≥48 hours without antipyretics 3, 4
• Resolution or significant improvement of symptoms 3
• Stable hemodynamic parameters for ≥24 hours without support 3, 4
• Adequate oral intake and urine output (>0.5 mL/kg/hour in adults) 3
• Laboratory parameters returning to normal ranges 3

Post-discharge instructions: Monitor temperature twice daily and return immediately if fever rises to ≥38°C on two consecutive readings or if any warning signs develop. 3

Special Populations

Pregnant women with confirmed or suspected dengue should be hospitalized due to risk of maternal death, hemorrhage, preeclampsia, and vertical transmission. 3 Acetaminophen remains the safest analgesic option. 3

For children, acetaminophen dosing should be carefully calculated based on weight, and crystalloids remain first-line for resuscitation with colloids reserved for severe cases. 1