What is the treatment for dengue fever?

Treatment of Dengue Fever

There is no specific antiviral therapy for dengue fever; treatment is entirely symptomatic with acetaminophen for pain/fever, aggressive oral or intravenous fluid management based on disease severity, and strict avoidance of aspirin and NSAIDs due to bleeding risk. 1

Disease Classification and Risk Stratification

Dengue presents across a spectrum that determines management approach:

• Dengue without warning signs: Mild febrile illness managed as outpatient 2
• Dengue with warning signs: Requires hospitalization and close monitoring 2
• Severe dengue: Includes dengue shock syndrome (DSS), severe bleeding, or organ impairment with 1-5% mortality if untreated, but <0.5% with proper care 1, 2

The disease follows a characteristic triphasic course: febrile phase, critical phase (days 3-7 when plasma leakage occurs), and recovery phase. 1, 3

Pain and Fever Management

Use acetaminophen (paracetamol) exclusively for symptom relief:

• Adults: 10-15 mg/kg every 4-6 hours, maximum 4 g/day 4
• Children: 10-15 mg/kg per dose, carefully weight-based 4
• Pregnant women: Acetaminophen remains the safest option 2, 4

Absolutely contraindicated medications:

• Never use aspirin or NSAIDs - these significantly increase bleeding risk due to antiplatelet effects and are contraindicated even when dengue cannot be excluded 1, 2, 4

Fluid Management Strategy

For Patients WITHOUT Shock (Dengue Fever or Dengue with Warning Signs)

• Aggressive oral hydration: Target >2,500-3,000 mL daily using water, oral rehydration solutions, cereal-based gruels, soup, or rice water 1, 2
• Encourage 5 or more glasses of fluid throughout the day 1
• Avoid soft drinks due to high osmolality 1
• Critical pitfall: Do NOT give routine bolus IV fluids to patients with severe febrile illness who are not in shock - this increases fluid overload and respiratory complications without improving outcomes 1

For Dengue Shock Syndrome (DSS)

Initial resuscitation protocol:

• Administer 20 mL/kg of isotonic crystalloid (Ringer's lactate or 0.9% normal saline) as rapid bolus over 5-10 minutes 1, 2
• Reassess immediately after each bolus for signs of improvement (improved tachycardia, tachypnea, capillary refill) 1
• If shock persists, repeat crystalloid boluses up to total of 40-60 mL/kg in the first hour before escalating therapy 1

Colloid solutions for refractory shock:

• Colloids (dextran, gelafundin, or albumin) provide faster resolution of shock (RR 1.09,95% CI 1.00-1.19) and reduce total volume needed (mean 31.7 mL/kg versus 40.63 mL/kg for crystalloids) 1
• Reserve colloids for severe shock with pulse pressure <10 mmHg or persistent shock despite adequate crystalloid resuscitation 1, 2

Vasopressor support for refractory shock:

• Cold shock with hypotension: Titrate epinephrine as first-line 1
• Warm shock with hypotension: Titrate norepinephrine as first-line 1
• Begin peripheral inotropic support immediately if central access unavailable - delays in vasopressor therapy significantly increase mortality 1
• Target mean arterial pressure appropriate for age and ScvO2 >70% 1

Critical Monitoring Parameters

Daily laboratory monitoring:

• Complete blood count to track platelet counts and hematocrit 1, 2
• Rising hematocrit indicates ongoing plasma leakage and need for continued resuscitation 1
• Falling hematocrit suggests successful plasma expansion 1

Warning signs requiring immediate escalation:

• High hematocrit with rapidly falling platelet count 1
• Severe abdominal pain, persistent vomiting 1
• Lethargy, restlessness, altered mental status 1
• Mucosal bleeding 1
• Signs of fluid overload: hepatomegaly, pulmonary rales, respiratory distress 1

Adequate tissue perfusion indicators:

• Normal capillary refill time, absence of skin mottling 1
• Warm and dry extremities, well-felt peripheral pulses 1
• Return to baseline mental status 1
• Adequate urine output (>0.5 mL/kg/hour in adults) 1

Management of Complications

Fluid overload (critical pitfall):

• Stop fluid resuscitation immediately if hepatomegaly or pulmonary rales develop 1
• Switch from aggressive fluids to inotropic support rather than continuing fluid boluses 1
• Evidence shows aggressive shock management followed by judicious fluid removal decreased pediatric ICU mortality from 16.6% to 6.3% 1
• Consider continuous renal replacement therapy (CRRT) if fluid overload >10% develops 1

Significant bleeding:

• Blood transfusion may be necessary 1, 2
• Target hemoglobin >10 g/dL if ScvO2 <70% 1

Hospital Admission Criteria

Admit patients with any of the following:

• Dengue shock syndrome (narrow pulse pressure ≤20 mmHg, hypotension, hemodynamic instability) 2
• Severe plasma leakage, severe bleeding, or organ failure 2
• Rising hematocrit (>20% increase from baseline) 2
• Thrombocytopenia ≤100,000/mm³, particularly if declining rapidly 2
• Pregnant women with confirmed or suspected dengue (risk of maternal death, hemorrhage, preeclampsia, vertical transmission) 2

Discharge Criteria

Patients can be safely discharged when ALL criteria met:

• Afebrile for ≥48 hours without antipyretics 2
• Resolution or significant improvement of symptoms 2
• Stable hemodynamic parameters for ≥24 hours without support 2
• Adequate oral intake and urine output (>0.5 mL/kg/hour in adults) 2
• Laboratory parameters returning to normal ranges 2

Post-discharge instructions:

• Monitor temperature twice daily 2
• Return immediately if temperature ≥38°C on two consecutive readings or any warning signs develop 2

Key Clinical Pitfalls to Avoid

• Delaying fluid resuscitation in established dengue shock syndrome - once hypotension occurs, cardiovascular collapse may rapidly follow 1
• Administering excessive fluid boluses in patients without shock - leads to fluid overload and respiratory complications 1
• Failing to recognize the critical phase (days 3-7) when plasma leakage can rapidly progress to shock 1, 4
• Using restrictive fluid strategies in dengue shock - no survival benefit and may worsen outcomes; aggressive fluid management achieves near 100% survival 1
• Continuing aggressive fluid resuscitation once signs of fluid overload appear - switch to inotropic support instead 1