What is the appropriate management for a 29-year-old male with elevated hemoglobin (Hb) and hematocrit (Hct), presenting with a 5-day history of fever, body pain, cough, colds, and an episode of epistaxis (nosebleeding)?

Dengue Fever Management

This patient most likely has dengue fever and requires immediate outpatient supportive care with daily monitoring of complete blood counts, strict avoidance of NSAIDs/aspirin, and urgent hospitalization if warning signs develop. 1

Clinical Presentation Consistent with Dengue

The constellation of 5 days of fever, body pain (myalgia), cough, colds, and epistaxis (nosebleeding) in a young adult with elevated hemoglobin and hematocrit is highly characteristic of dengue fever, particularly during the critical phase when plasma leakage causes hemoconcentration 1. The elevated hematocrit is a key warning sign indicating capillary leak and potential progression to dengue hemorrhagic fever or dengue shock syndrome 1.

Immediate Diagnostic Workup

• Order dengue PCR immediately if symptoms are 1-8 days post-onset, as this is the most sensitive diagnostic test during the acute phase 1
• Obtain complete blood count with platelet count to assess for thrombocytopenia and monitor hematocrit trends 1
• Monitor hematocrit daily - rising hematocrit with falling platelets indicates high risk of shock and requires hospitalization 1
• Check liver enzymes (ALT, AST) as transaminitis is common in dengue 1

Critical Management Decisions

Outpatient vs. Inpatient Management

Manage as outpatient with daily FBC monitoring if the patient has 1:

• Stable vital signs
• Adequate oral intake
• No warning signs (see below)
• Reliable follow-up available

Immediate hospitalization is required if any warning signs present 1:

• Abdominal pain or tenderness
• Persistent vomiting
• Clinical fluid accumulation (ascites, pleural effusion)
• Mucosal bleeding (beyond minor epistaxis)
• Lethargy or restlessness
• Liver enlargement >2 cm
• Rising hematocrit with rapidly falling platelet count

Supportive Care Protocol

• Provide aggressive oral hydration - encourage 2-3 liters of oral fluids daily to maintain adequate perfusion 1
• Avoid aspirin and NSAIDs completely - use acetaminophen only for fever control, as antiplatelet agents increase bleeding risk 1
• Rest and avoid strenuous activity until fever resolves and platelet count normalizes 1
• Daily monitoring of complete blood count, hematocrit, and platelet count until clinical improvement 1

Critical Pitfalls to Avoid

• Do not dismiss elevated hematocrit as polycythemia vera - in the context of acute febrile illness with bleeding, this represents hemoconcentration from plasma leakage, not true polycythemia 1, 2
• Do not use phlebotomy - despite elevated hemoglobin/hematocrit, this is relative polycythemia from volume depletion, not absolute erythrocytosis requiring phlebotomy 2, 3
• Do not prescribe NSAIDs or aspirin - these are absolutely contraindicated due to bleeding risk and platelet dysfunction 1
• Do not delay hospitalization if warning signs develop - dengue shock syndrome can progress rapidly within hours 1

Alternative Diagnoses to Consider

While dengue is most likely, briefly evaluate for 1:

• Malaria - obtain thick/thin blood smears if travel to endemic area, though fever pattern and epistaxis less typical 1
• Rickettsial diseases - consider if tick exposure history, though rash/eschar typically present 1
• Leptospirosis - if water exposure history, though typically causes jaundice 1

Follow-up Protocol

• Daily clinic visits or phone contact for first 3-5 days to monitor for warning signs 1
• Repeat CBC daily until hematocrit stabilizes and platelet count begins rising 1
• Return immediately if develops severe abdominal pain, persistent vomiting, bleeding from any site, altered mental status, or signs of shock 1
• Expect clinical improvement by day 6-7 of illness with defervescence and rising platelet count 1