What is the treatment for dengue?

Treatment of Dengue

Dengue treatment is primarily supportive with no specific antiviral therapy available; management centers on careful fluid resuscitation, acetaminophen for symptom control, and vigilant monitoring during the critical phase (days 3-7) to prevent progression to shock. 1, 2

General Management Principles

Symptomatic management is the cornerstone of dengue treatment, as there is no approved antiviral therapy. 1, 3 The disease follows a characteristic triphasic course (febrile phase, critical phase, recovery phase), with the critical phase typically occurring on days 3-7 of illness when plasma leakage can rapidly progress to shock. 1, 2

Key Monitoring Requirements

• Daily complete blood count monitoring is essential to track platelet counts and hematocrit levels, particularly in patients at risk of progression to shock. 1, 4
• Watch for warning signs of severe disease: severe abdominal pain, persistent vomiting, mucosal bleeding, lethargy or restlessness, and high hematocrit with rapidly falling platelet count. 1, 5
• 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 (>0.5 mL/kg/hour in adults). 1

Pain and Fever Management

• Use acetaminophen (paracetamol) at standard doses as the only acceptable analgesic. 1, 4, 5
• Never use aspirin or NSAIDs under any circumstances due to increased bleeding risk and platelet dysfunction. 1, 4, 5

Fluid Management Strategy

For Patients Without Shock (Dengue Without Warning Signs or Mild Warning Signs)

• Aggressive oral hydration is the primary intervention, with a target fluid intake of approximately 2,500-3,000 mL daily. 1, 4
• Use any locally available fluids including water, oral rehydration solutions, cereal-based gruels, soup, and rice water; avoid soft drinks due to high osmolality. 1
• Encourage 5 or more glasses of fluid throughout the day, as this volume reduces hospitalization rates. 1
• Avoid routine bolus intravenous fluids in 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, 4, 5

Initial Resuscitation Protocol:

• 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
• Colloid solutions (dextran, gelafundin, or albumin) provide faster resolution of shock compared to crystalloids alone (RR 1.09,95% CI 1.00-1.19) and reduce total volume needed (mean 31.7 mL/kg versus 40.63 mL/kg for crystalloids). 1
• Consider colloids for severe dengue shock with pulse pressure <10 mmHg. 4

Critical Monitoring During Resuscitation:

• Stop fluid resuscitation immediately if hepatomegaly or pulmonary rales develop, as these signal fluid overload. 1
• Watch for signs of improvement: resolution of tachycardia and tachypnea, improved capillary refill, and adequate urine output. 1
• Avoid overhydration, particularly during the recovery phase, as it can lead to pulmonary edema. 1

Management of Refractory Shock

If shock persists despite adequate fluid resuscitation:

• For cold shock with hypotension: titrate epinephrine as first-line vasopressor. 1, 5
• For warm shock with hypotension: titrate norepinephrine as first-line vasopressor. 1, 5
• 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
• Target mean arterial pressure appropriate for age and maintain ScvO2 >70%. 1

Management of Complications

Bleeding

• Blood transfusion may be necessary in cases of significant bleeding, with close monitoring of hemoglobin and hematocrit. 1, 5
• Prophylactic platelet transfusion is not recommended. 6

Organ Involvement

• Obtain blood and urine cultures and chest radiograph if fever persists beyond the expected course to diagnose secondary bacterial infections. 4
• Monitor with continuous cardiac telemetry and pulse oximetry for patients with dengue shock syndrome. 4
• Secondary hemophagocytic lymphohistiocytosis is a potentially fatal complication that needs recognition, as specific management with steroids or intravenous immunoglobulin may improve outcomes. 6

Hospitalization Criteria

Hospitalize patients with:

• Warning signs: severe abdominal pain, persistent vomiting, mucosal bleeding, lethargy/restlessness, rising hematocrit with rapidly falling platelet count, hepatomegaly, or clinical fluid accumulation. 5
• Severe dengue: severe plasma leakage, severe bleeding, organ failure, or dengue shock syndrome (narrow pulse pressure ≤20 mmHg or hypotension). 4
• Pregnant women with confirmed or suspected dengue due to risk of maternal death, hemorrhage, preeclampsia, and vertical transmission. 4
• Rising hematocrit (>20% increase from baseline) or thrombocytopenia ≤100,000/mm³, particularly when declining rapidly. 4

Discharge Criteria

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

• Afebrile for ≥48 hours without antipyretics. 4, 5
• Resolution or significant improvement of symptoms. 4, 5
• Stable hemodynamic parameters for ≥24 hours without support (normal heart rate, stable blood pressure, normal capillary refill time). 4, 5
• Adequate oral intake and urine output (>0.5 mL/kg/hour in adults). 4, 5
• Laboratory parameters returning to normal ranges. 4, 5

Post-Discharge Instructions:

• Monitor and record temperature twice daily. 4
• Return immediately if temperature rises to ≥38°C on two consecutive readings or if any warning signs develop. 4

Critical Pitfalls to Avoid

• Do not delay fluid resuscitation in established dengue shock syndrome, as cardiovascular collapse may rapidly follow once hypotension occurs. 1
• Do not continue aggressive fluid resuscitation once signs of fluid overload appear; switch to inotropic support instead. 1
• Do not use restrictive fluid strategies in established dengue shock syndrome, as moderate-quality evidence shows no survival benefit from colloid restriction, and aggressive fluid management demonstrates near 100% survival. 1
• Do not administer excessive fluid boluses in patients without shock, as this leads to fluid overload and respiratory complications. 1
• Do not fail to recognize the critical phase (days 3-7) when plasma leakage can rapidly progress to shock. 1, 2
• Do not change management based solely on persistent fever pattern without clinical deterioration or new findings, as persistent fever is common and typically resolves within 5 days. 4