What is the treatment for dengue fever?

Treatment of Dengue Fever

Dengue fever treatment is primarily supportive with no specific antiviral therapy available, focusing on symptomatic management with acetaminophen for pain/fever, adequate hydration, and careful monitoring for progression to severe disease. 1

General Management Approach

Symptomatic Treatment

• Acetaminophen (paracetamol) is the only recommended analgesic and antipyretic, dosed at 10-15 mg/kg every 4-6 hours, not exceeding 4 g/day in adults. 1, 2
• Absolutely avoid aspirin and NSAIDs under any circumstances due to significantly increased bleeding risk from thrombocytopenia and platelet dysfunction. 1, 3
• Monitor liver function tests when using acetaminophen, particularly in patients with pre-existing hepatic disease or signs of hepatic involvement. 2

Hydration Strategy

For patients without shock (dengue fever or dengue with warning signs):

• Encourage aggressive oral hydration with a target of 2,500-3,000 mL daily (approximately 5 or more glasses throughout the day). 1, 3
• Use any locally available fluids including water, oral rehydration solutions, cereal-based gruels, soup, and rice water—avoid soft drinks due to high osmolality. 1
• Oral rehydration solutions are appropriate for moderate dehydration. 1, 3

Critical pitfall: Avoid routine bolus intravenous 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. 1

Monitoring Protocol

Essential Laboratory Monitoring

• Perform daily complete blood count to track platelet counts and hematocrit levels, particularly during the critical phase (days 3-7 of illness). 1, 3
• Rising hematocrit indicates ongoing plasma leakage and need for escalation of care. 1
• Falling hematocrit after resuscitation suggests successful plasma expansion. 1

Warning Signs Requiring Immediate Escalation

Monitor for these indicators of progression to severe dengue: 1, 3

• Persistent vomiting or severe abdominal pain
• Lethargy, restlessness, or altered mental status
• Mucosal bleeding (gum bleeding, epistaxis, hematemesis)
• High hematocrit with rapidly falling platelet count
• Clinical fluid accumulation (ascites, pleural effusion)

Management of Dengue Shock Syndrome

If shock develops (narrow pulse pressure ≤20 mmHg, hypotension, cold extremities, altered mental status):

Immediate Resuscitation Protocol

• Administer 20 mL/kg of isotonic crystalloid (Ringer's lactate or 0.9% normal saline) as a rapid bolus over 5-10 minutes. 1, 3
• Reassess immediately after each bolus for signs of improvement (improved tachycardia, tachypnea, capillary refill, mental status). 1
• Repeat crystalloid boluses up to a total of 40-60 mL/kg in the first hour if shock persists before escalating therapy. 1

Colloid Solutions

• For severe dengue shock (pulse pressure <10 mmHg) or refractory shock, colloids provide faster resolution (RR 1.09,95% CI 1.00-1.19) and require less total volume (mean 31.7 mL/kg versus 40.63 mL/kg for crystalloids). 1
• Alternative colloids include gelafundin or albumin if dextran is unavailable. 1

Management of Refractory Shock

If shock persists despite 40-60 mL/kg of fluid in the first hour: 1

• Switch strategy from aggressive fluid administration to inotropic support rather than continuing fluid boluses
• For cold shock with hypotension: titrate epinephrine as first-line vasopressor
• For warm shock with hypotension: titrate norepinephrine as first-line vasopressor
• Target mean arterial pressure appropriate for age and maintain ScvO2 >70%
• Begin peripheral inotropic support immediately if central venous access is not readily available, as delays in vasopressor therapy significantly increase mortality

Critical Monitoring During Resuscitation

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

• Hepatomegaly (enlarging liver edge)
• Pulmonary rales on lung examination
• Respiratory distress or increasing oxygen requirement

Signs of adequate resuscitation include: 1

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

Management of Complications

Hemorrhagic Complications

• Blood transfusion may be necessary for significant bleeding; target hemoglobin >10 g/dL if ScvO2 <70%. 1
• Platelet transfusion is generally reserved for active bleeding with severe thrombocytopenia, not for prophylaxis based on platelet count alone. 1

Fluid Overload in Recovery Phase

• After initial shock reversal, judicious fluid removal may be necessary—evidence shows that aggressive shock management followed by fluid removal decreased pediatric ICU mortality from 16.6% to 6.3%. 1
• Consider continuous renal replacement therapy (CRRT) if fluid overload >10% develops, as outcomes are better when initiated early. 1

Discharge Criteria

Patients can be safely discharged when ALL of the following are met: 3

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

Post-discharge instructions: 3

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

Special Populations

Pregnant Women

• Acetaminophen remains the safest analgesic option for pregnant women with dengue fever. 3, 2
• Pregnant women with confirmed or suspected dengue should be hospitalized due to risk of maternal death, hemorrhage, preeclampsia, and vertical transmission. 3
• Test by NAAT for both dengue and Zika virus, regardless of outbreak patterns. 3

Children

• Acetaminophen dosing should be carefully calculated based on weight (10-15 mg/kg per dose). 1, 2
• For dengue shock syndrome in children, the same aggressive crystalloid resuscitation protocol achieves near 100% survival when properly administered. 1
• Blood pressure alone is not a reliable endpoint in children—use clinical perfusion parameters instead. 1

Critical Pitfalls to Avoid

• Never delay fluid resuscitation in established dengue shock syndrome—once hypotension occurs, cardiovascular collapse may rapidly follow, and delays significantly increase mortality. 1
• Do not fail to recognize the critical phase (typically days 3-7 of illness) when plasma leakage can rapidly progress to shock. 1, 2
• Avoid overhydration, which can lead to pulmonary edema, particularly during the recovery phase. 1
• Do not continue aggressive fluid resuscitation once signs of fluid overload appear—switch to inotropic support instead. 1
• Never use aspirin or NSAIDs when dengue cannot be excluded. 3