What is the management and prevention of dengue (Dengue virus infection)?

Dengue Management and Prevention

Clinical Presentation and Diagnosis

Dengue presents with fever, headache, retro-orbital pain, myalgia, arthralgia, and rash 4-8 days after mosquito exposure, and diagnosis requires PCR/NAAT testing within the first 7 days of symptoms or IgM capture ELISA after 5-7 days. 1

Key Diagnostic Approach

• Perform PCR/NAAT on serum for patients with symptoms ≤7 days from onset, as this is most effective during the viremic phase 1
• Order IgM capture ELISA for patients with symptoms >5-7 days if PCR is unavailable or negative 1
• NS1 antigen detection is useful from day 1 to day 10 after symptom onset 2
• Rapid diagnostic tests combining NS1 antigen and IgG have very high positive likelihood ratios and optimize management 1
• Document vaccination history to avoid cross-reactivity with other flaviviruses (yellow fever, Japanese encephalitis, tick-borne encephalitis) 1

Classification System

The WHO revised classification categorizes dengue into three severity groups 3:

• Dengue without Warning Signs: Acute febrile illness with typical symptoms but no warning signs 2
• Dengue with Warning Signs: Presence of persistent vomiting, abdominal pain/tenderness, clinical fluid accumulation, mucosal bleeding, lethargy/restlessness, hepatomegaly, or hematocrit rise with concurrent thrombocytopenia 2
• Severe Dengue: Severe plasma leakage, severe bleeding, or organ failure 3

Outpatient vs. Inpatient Management Decision

Hospitalize immediately if any of the following are present:

• Warning signs (persistent vomiting, abdominal pain, mucosal bleeding, lethargy/restlessness, hepatomegaly, rising hematocrit with falling platelets) 2
• Severe plasma leakage, severe bleeding, organ failure, or dengue shock syndrome 1
• Narrow pulse pressure ≤20 mmHg or hypotension 1
• Thrombocytopenia ≤100,000/mm³, particularly when declining rapidly 1
• Rising hematocrit >20% increase from baseline 1
• Pregnant women with confirmed or suspected dengue due to risk of maternal death, hemorrhage, preeclampsia, and vertical transmission 1

Outpatient management is appropriate when:

• Platelet count >100,000/mm³ without rapid decline 1
• Stable hematocrit without hemoconcentration 1
• No warning signs present 1

Outpatient Management Protocol

For dengue without warning signs, manage with aggressive oral hydration (>2500ml daily), acetaminophen for symptom relief, and daily monitoring for warning signs. 1

Specific Instructions

• Ensure oral rehydration solutions for moderate dehydration, targeting >2500ml daily 1
• Acetaminophen at standard doses for pain and fever relief 1
• NEVER use aspirin or NSAIDs under any circumstances due to high bleeding risk 1
• Daily complete blood count monitoring to track platelet counts and hematocrit levels 1
• Monitor for warning signs daily, which typically appear around day 3-7 of illness during defervescence 2

Post-Discharge Monitoring

• Monitor and record temperature twice daily 1
• Return immediately if temperature rises to ≥38°C on two consecutive readings or if any warning signs develop 1

Inpatient Management

Fluid Management for Dengue Shock Syndrome

Administer an initial fluid bolus of 20 mL/kg isotonic crystalloid over 5-10 minutes with immediate reassessment for patients with dengue shock syndrome. 1

• Reassess immediately after bolus completion and consider additional boluses if necessary 1
• Consider colloid solutions for severe dengue shock with pulse pressure <10 mmHg, as colloids show benefit for time to resolution of shock compared to crystalloids alone 1
• Avoid over-resuscitation, as excessive fluids can worsen outcomes given the underlying plasma leakage pathophysiology 2

Recognizing Dengue Shock Syndrome

Dengue shock is distinguished by 2:

• Systolic blood pressure <90 mmHg for >30 minutes 2
• Pulse pressure <20 mmHg persisting despite initial fluid resuscitation (this is an earlier and more sensitive indicator than absolute hypotension) 2
• Signs of end-organ hypoperfusion: cold, clammy extremities, livedo reticularis, capillary refill time ≥3 seconds, elevated lactate >2 mmol/L 2

Management of Complications

• For significant bleeding, blood transfusion may be necessary 1
• For persistent tissue hypoperfusion despite adequate fluid resuscitation, use vasopressors such as dopamine or epinephrine 1
• Obtain blood and urine cultures and chest radiograph if fever persists to diagnose secondary bacterial infections 1
• Monitor with continuous cardiac telemetry and pulse oximetry for patients with dengue shock syndrome 1

Persistent Fever Management

• Persistent fever typically resolves within 5 days of treatment initiation 1
• Broaden management to include coverage for potential secondary infections if patients remain hemodynamically unstable 1
• Do not change antibiotics or management based solely on persistent fever pattern without clinical deterioration or new findings 1

Discharge Criteria

Patients can be safely discharged when they meet ALL of the following criteria: 1

• Afebrile for ≥48 hours without antipyretics 1
• Resolution or significant improvement of symptoms 1
• Stable hemodynamic parameters for ≥24 hours without support (normal heart rate, stable blood pressure, normal capillary refill time) 1
• Adequate oral intake 1
• Adequate urine output (>0.5 mL/kg/hour in adults) 1
• Laboratory parameters returning to normal ranges 1

Special Populations

Pregnant Women

• Test by NAAT for both dengue and Zika virus, regardless of outbreak patterns, due to risk of adverse outcomes 1
• Acetaminophen is the safest analgesic option for pregnant women with dengue 1
• Hospitalize all pregnant women with confirmed or suspected dengue 1

Children

• Acetaminophen dosing should be carefully calculated based on weight 1
• 90% of dengue hemorrhagic fever cases occur in children <15 years of age 4

Prevention

Day-biting mosquitoes of the genus Aedes, particularly Aedes aegypti, are the primary vectors of dengue fever. 1

Vector Control Measures

• Aedes aegypti mosquitoes are both diurnal and container breeders, requiring particular prevention and control measures 5
• Vector control is the only alternative for stopping disease spread, as no specific antiviral therapy exists and vaccine availability remains limited 6
• Eliminate standing water containers where Aedes mosquitoes breed 5
• Use protective measures during daytime hours when these mosquitoes are most active 5

Critical Pitfalls to Avoid

• Never use aspirin or NSAIDs when dengue cannot be excluded due to high bleeding risk 1
• Do not delay fluid resuscitation in patients showing signs of shock 1
• Narrow pulse pressure (<20 mmHg) is an earlier and more sensitive indicator of dengue shock than absolute hypotension—monitor closely 2
• Warning signs typically appear around day 3-7 of illness during defervescence—this is the critical monitoring period 2
• Early recognition of warning signs and appropriate management can reduce case-fatality rate to <0.5% 2