Hydrocortisone in Dengue Fever Management
Hydrocortisone should NOT be used routinely in dengue fever or dengue shock syndrome, as there is insufficient evidence to support its use and it may cause harm. 1, 2
Evidence Summary
For Dengue Shock Syndrome
The evidence for hydrocortisone in dengue shock syndrome is conflicting and of very low quality:
One older randomized trial from 1975 showed reduced mortality with high-dose hydrocortisone (18.75% vs 44% case fatality rate, statistically significant) in 98 children with dengue shock syndrome. 3 However, this single positive study is now 50 years old and has significant methodological limitations. 4
A 2014 Cochrane systematic review found no evidence that corticosteroids reduce death (RR 0.68,95% CI 0.42-1.11), need for blood transfusion (RR 1.08,95% CI 0.52-2.24), or serious complications in dengue shock syndrome across four trials with 284 participants. 2 The quality of evidence was rated as very low. 1
The American College of Critical Care Medicine (2009) reviewed the pediatric literature and noted that while one RCT showed improved outcomes with hydrocortisone in dengue shock, a second study was underpowered and showed no effect. 4 The committee makes no recommendation for routine hydrocortisone use in dengue shock. 4
Current Guideline Recommendations
The American College of Critical Care Medicine recommends hydrocortisone ONLY for:
- Patients with absolute adrenal insufficiency (peak cortisol <18 μg/dL after ACTH stimulation), OR
- Adrenal-pituitary axis failure with catecholamine-resistant shock 4
For dengue shock specifically, the recommended approach is:
- Aggressive fluid resuscitation with 20 mL/kg isotonic crystalloid boluses 5, 6
- Colloid solutions if shock persists after crystalloid resuscitation 5
- Vasopressors (epinephrine for cold shock, norepinephrine for warm shock) for refractory shock 5
- NOT routine corticosteroids 1, 2
Critical Pitfalls to Avoid
Do not use corticosteroids routinely in dengue fever or dengue shock syndrome outside of a clinical trial, as the evidence is insufficient and potential harm exists. 1, 2
Do not delay definitive treatment (fluid resuscitation and vasopressors) while considering corticosteroid therapy, as delays in appropriate management significantly increase mortality. 5
Do not confuse dengue shock with septic shock - the pathophysiology differs (plasma leakage vs. distributive shock), and treatment algorithms are not identical. 5, 7
When Hydrocortisone Might Be Considered
If you are managing a patient with dengue shock syndrome who has:
- Documented absolute adrenal insufficiency (cortisol <18 μg/dL), then hydrocortisone 2-50 mg/kg/day is appropriate 4
- Catecholamine-resistant shock despite adequate fluid resuscitation and high-dose vasopressors, AND you suspect adrenal insufficiency, then consider ACTH stimulation testing and empiric hydrocortisone 4
The dose range is wide (2-50 mg/kg/day) and should be titrated to resolution of shock, then weaned as tolerated to minimize long-term toxicities. 4
Bottom Line
Focus on proven interventions for dengue shock syndrome: aggressive crystalloid resuscitation (20 mL/kg boluses up to 40-60 mL/kg in first hour), colloids for refractory shock, and early vasopressor support. 5 Hydrocortisone has no established role unless adrenal insufficiency is documented or strongly suspected in catecholamine-resistant shock. 4, 1, 2