What is the treatment for dengue fever?

Dengue Fever Treatment

Dengue treatment is primarily supportive with no specific antiviral therapy available; the cornerstone is judicious fluid management tailored to disease severity, acetaminophen for fever control, and strict avoidance of NSAIDs/aspirin due to bleeding risk. 1, 2

Initial Risk Stratification and Classification

Classify patients into one of three categories to guide management 2, 3:

• Dengue without warning signs: Outpatient management with oral hydration
• Dengue with warning signs: Hospital admission for close monitoring and IV fluid consideration
• Severe dengue: ICU admission for aggressive resuscitation

Monitor for warning signs that predict progression to severe disease 1, 2:

• Persistent vomiting
• Severe abdominal pain
• Lethargy or restlessness
• Mucosal bleeding
• Rising hematocrit with rapidly falling platelet count
• Clinical fluid accumulation (ascites, pleural effusion)

The critical phase typically occurs on days 3-7 of illness when plasma leakage can rapidly progress to shock 2, 4.

Fluid Management for Non-Severe Dengue

For patients without shock, oral rehydration is the appropriate first-line approach. 2, 4

• Target approximately 2,500-3,000 mL daily oral intake, which reduces hospitalization rates 1
• Use any locally available fluids: water, oral rehydration solutions, cereal-based gruels, soup, rice water 1
• Avoid soft drinks due to high osmolality 1
• Avoid routine bolus IV 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 2

Fluid Management for Dengue Shock Syndrome

Administer 20 mL/kg of isotonic crystalloid (0.9% normal saline or Ringer's lactate) as a rapid bolus over 5-10 minutes, with immediate reassessment after each bolus. 1, 2, 5

Initial Resuscitation Protocol

• If shock persists after initial bolus, repeat crystalloid boluses up to 40-60 mL/kg in the first hour 1, 2
• Crystalloids are the first-line fluid for resuscitation 2, 5
• Colloids may be beneficial in severe cases when available, providing faster resolution of shock (RR 1.09,95% CI 1.00-1.19) and reducing total volume needed (mean 31.7 mL/kg versus 40.63 mL/kg for crystalloids) 2
• Alternative colloids include gelafundin or albumin if dextran is unavailable 2

Monitoring During Resuscitation

Target these clinical endpoints 1, 2:

• Normal capillary refill time
• Absence of skin mottling
• Warm and dry extremities
• Well-felt peripheral pulses
• Return to baseline mental status
• Adequate urine output
• Improvement in tachycardia and tachypnea

Stop fluid resuscitation immediately if signs of fluid overload develop 1, 2:

• Hepatomegaly
• Pulmonary rales on lung examination
• Respiratory distress

Monitor hematocrit closely, as rising hematocrit indicates ongoing plasma leakage and need for continued resuscitation 1.

Management of Refractory Shock

Switch from fluids to inotropic support rather than continuing aggressive fluid administration if shock persists despite adequate fluid resuscitation. 1, 2

• For cold shock with hypotension: Titrate epinephrine as first-line vasopressor 1, 2
• For warm shock with hypotension: Titrate norepinephrine as first-line vasopressor 1, 2, 6
• 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 2
• Target mean arterial pressure appropriate for age and maintain ScvO2 >70% 2

Symptomatic Management

• Use acetaminophen (paracetamol) ONLY for pain and fever management 1, 2
• Strictly avoid aspirin and NSAIDs due to increased bleeding risk 2, 4, 3
• Resume age-appropriate diet as soon as appetite returns 2

Monitoring Parameters

Perform daily complete blood count monitoring to track 2, 4:

• Platelet counts
• Hematocrit levels

Management of Bleeding Complications

• Blood transfusion may be necessary in cases of significant bleeding 2, 4
• Maintain hemoglobin at a minimum of 10 g/dL, as oxygen delivery depends on hemoglobin concentration 1
• Prophylactic platelet transfusion is not recommended 7

Critical Pitfalls to Avoid

• Do not administer excessive fluid boluses in patients without shock, which leads to fluid overload and respiratory complications 2, 4
• Do not delay fluid resuscitation in established dengue shock syndrome, as cardiovascular collapse may rapidly follow 2
• Do not continue aggressive fluid resuscitation once signs of fluid overload appear; switch to inotropic support instead 1, 2
• 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 2
• Do not fail to recognize the critical phase (days 3-7) when plasma leakage can rapidly progress to shock 2, 4
• Blood pressure alone is not a reliable endpoint in children 2

Special Considerations

Evidence from aggressive shock management combined with judicious fluid removal decreased pediatric ICU mortality from 16.6% to 6.3% 2. In resource-rich settings with persistent shock, consider invasive monitoring to guide therapy 2. Secondary hemophagocytic lymphohistiocytosis is a potentially fatal complication that may require specific management with steroids or intravenous immunoglobulin 7.