Dengue Fever Management
Dengue fever management is primarily supportive, centered on aggressive fluid resuscitation, acetaminophen for symptom control, and meticulous monitoring for warning signs that herald progression to severe disease. 1, 2
Risk Stratification and Triage
The first critical step is determining whether the patient requires hospitalization or can be managed as an outpatient:
Hospitalize immediately if any of the following are present:
- Warning signs: persistent vomiting, abdominal pain/tenderness, clinical fluid accumulation, mucosal bleeding, lethargy/restlessness, hepatomegaly 3
- Hematocrit rise >20% from baseline with concurrent thrombocytopenia 1, 3
- Platelet count ≤100,000/mm³, particularly if declining rapidly 1
- Dengue shock syndrome: pulse pressure ≤20 mmHg, hypotension (SBP <90 mmHg), or signs of end-organ hypoperfusion 3
- Pregnant women with confirmed or suspected dengue 1
- Severe plasma leakage, severe bleeding, or organ failure 1
Outpatient management is appropriate when:
- No warning signs present 1
- Platelet count >100,000/mm³ without rapid decline 1
- Stable hematocrit without hemoconcentration 1
- Patient can maintain adequate oral hydration 1
Diagnostic Confirmation
Order dengue PCR/NAAT on serum for patients with symptoms for 1-7 days 1, as this is the most sensitive test during the viremic phase 3. If symptoms have been present for >5-7 days, order IgM capture ELISA instead 1, 2. NS1 antigen detection is useful from day 1 to day 10 after symptom onset 3. For pregnant women, test by NAAT for both dengue and Zika virus regardless of outbreak patterns due to risk of adverse outcomes 1.
Fluid Management Strategy
For Patients Without Shock (Outpatient or Mild Cases)
Ensure oral fluid intake exceeding 2500 mL daily 1, 2, using oral rehydration solutions for moderate dehydration 1, 2. This aggressive oral hydration is the cornerstone of preventing progression to severe disease.
For Dengue Shock Syndrome
Administer 20 mL/kg isotonic crystalloid bolus over 5-10 minutes with immediate reassessment 1, 2. This rapid bolus approach differs fundamentally from typical septic shock management. You may need 2-3 boluses in profound shock 4. Consider colloid solutions (including albumin) for severe shock with pulse pressure <10 mmHg or when massive plasma leakage has occurred 1, 2, 4.
Critical pitfall: Narrow pulse pressure (<20 mmHg) is an earlier and more sensitive indicator of shock than absolute hypotension 3. However, avoid over-resuscitation, as excessive fluids worsen outcomes given the underlying plasma leakage pathophysiology 3. In resource-limited settings without mechanical ventilation and inotropic support, aggressive fluid boluses may increase mortality 1.
If persistent tissue hypoperfusion occurs despite adequate fluid resuscitation, use vasopressors such as dopamine or epinephrine 1, 2.
Symptomatic Management
Use acetaminophen at standard doses exclusively for pain and fever relief 1, 2. Never use aspirin or NSAIDs under any circumstances due to increased bleeding risk and platelet dysfunction 1, 2. This is an absolute contraindication. For pregnant women and children, acetaminophen remains the safest option, with pediatric dosing carefully calculated based on weight 1, 2.
Monitoring Protocol
Perform daily complete blood count to track platelet counts and hematocrit levels 1, 2. A hematocrit rise of 20% along with continuing platelet drop is a critical indicator for onset of shock 4.
Monitor continuously for warning signs 1, 2:
- Persistent vomiting
- Abdominal pain or tenderness
- Lethargy or restlessness
- Mucosal bleeding
- Rising hematocrit with falling platelet count
These warning signs typically appear around day 3-7 of illness, coinciding with defervescence 3. For dengue shock syndrome, use continuous cardiac telemetry and pulse oximetry 1, 2.
Management of Complications
For significant bleeding, blood transfusion may be necessary 1. Some patients develop disseminated intravascular coagulation requiring supportive therapy with blood products including fresh frozen plasma and platelet transfusions 4.
If fever persists beyond 5 days with hemodynamic instability, obtain blood and urine cultures and chest radiograph 1 to evaluate for secondary bacterial infections, and broaden management to include antibiotic coverage 1. However, avoid changing management based solely on persistent fever without clinical deterioration or new findings 1.
Avoid drainage of pleural effusion or ascites when possible, as polyserositis is common in dengue shock syndrome and drainage can lead to severe hemorrhages and sudden circulatory collapse 4.
Discharge Criteria
Patients can be safely discharged when ALL of the following are met 1, 2:
- Afebrile for ≥48 hours without antipyretics
- Resolution or significant improvement of symptoms
- Stable hemodynamic parameters for ≥24 hours without support (normal heart rate, stable blood pressure, normal capillary refill time)
- Adequate oral intake
- Adequate urine output (>0.5 mL/kg/hour in adults)
- Laboratory parameters returning to normal ranges
Post-discharge instructions: 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.
Disease Course and Prognosis
Dengue characteristically follows a triphasic course: febrile phase, critical phase (when warning signs appear), and recovery phase 5. More than 90% of cases take a mild course 5. With early recognition of warning signs and appropriate management, case-fatality rate can be reduced to <0.5% 3. Severe dengue with shock and/or mucosal hemorrhages carries a mortality of 1-5% 5.