What is the treatment for dengue infection?

Treatment of Dengue Infection

There is no specific antiviral therapy for dengue infection; treatment is entirely supportive, focusing on symptomatic management with acetaminophen for fever/pain, adequate hydration, and aggressive fluid resuscitation for those who develop shock. 1, 2

General Management Principles

• Symptomatic care is the cornerstone of dengue treatment since no approved antiviral medications exist for this infection 1, 3
• Acetaminophen (paracetamol) at standard doses is the only recommended analgesic for fever and pain relief 1, 4, 5
• Absolutely avoid aspirin and all NSAIDs under any circumstances due to significantly increased bleeding risk from platelet dysfunction and potential hemorrhagic complications 1, 4, 5

Risk Stratification and Monitoring

The disease follows a characteristic triphasic course (febrile phase, critical phase days 3-7, recovery phase), with the critical phase being when plasma leakage and shock can rapidly develop 6, 2:

• Daily complete blood count monitoring is essential to track platelet counts and hematocrit levels, particularly during days 3-7 of illness 1, 4, 5
• Watch for warning signs of progression to severe disease: persistent vomiting, severe abdominal pain, lethargy or restlessness, mucosal bleeding, high hematocrit with rapidly falling platelet count (≤100,000/mm³), and rising hematocrit (>20% increase from baseline) 1, 5
• Failing to recognize the critical phase (typically days 3-7) when plasma leakage can rapidly progress to shock is a major pitfall 1

Fluid Management for Non-Shock Patients

• Oral rehydration is appropriate for patients without signs of shock, targeting approximately 2,500-3,000 mL daily 1, 4, 5
• 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
• A critical pitfall is administering routine bolus intravenous fluids to patients with severe febrile illness who are NOT in shock, as this increases risk of fluid overload and respiratory complications without improving outcomes 1

Management of Dengue Shock Syndrome

When shock develops (narrow pulse pressure ≤20 mmHg, hypotension, or hemodynamic instability), immediate aggressive intervention is required 5:

Initial Resuscitation

• Administer 20 mL/kg of isotonic crystalloid (Ringer's lactate or 0.9% normal saline) as a rapid bolus over 5-10 minutes 1, 4, 5
• Reassess immediately after each bolus for signs of improvement: improved tachycardia, improved tachypnea, warming of extremities, improved capillary refill, improved mental status 1
• If shock persists, repeat crystalloid boluses up to a total of 40-60 mL/kg in the first hour before escalating therapy 1

Colloid Solutions

• For severe dengue shock (particularly with pulse pressure <10 mmHg), colloid solutions may be beneficial as moderate-quality evidence shows colloids achieve 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, 5
• Alternative colloids include gelafundin or albumin if dextran is unavailable 1

Critical Monitoring During Resuscitation

• Stop fluid resuscitation immediately if signs of fluid overload appear: hepatomegaly, pulmonary rales, or respiratory distress 1
• Rising hematocrit indicates ongoing plasma leakage and need for continued resuscitation; falling hematocrit suggests successful plasma expansion 1
• Monitor for adequate tissue perfusion: 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) 1, 5

Management of Refractory Shock

• If shock persists despite 40-60 mL/kg of crystalloid in the first hour, switch from aggressive fluid administration to inotropic support rather than continuing fluid boluses 1
• For cold shock with hypotension: titrate epinephrine as first-line vasopressor 1
• For warm shock with hypotension: titrate norepinephrine as first-line vasopressor 1
• Begin peripheral inotropic support immediately if central venous access is not readily available, as delays in vasopressor therapy are associated with major increases in mortality 1
• Target mean arterial pressure appropriate for age and maintain ScvO2 >70% 1

Post-Resuscitation Management

• After initial shock reversal, judicious fluid removal may be necessary, as evidence shows 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

Management of Bleeding Complications

• Blood transfusion may be necessary in cases of significant bleeding 1, 4
• Target hemoglobin >10 g/dL if ScvO2 <70% 1

Respiratory Support

• For patients with respiratory distress and/or persistent hypoxemia despite oxygen therapy, consider non-invasive ventilation if available and staff is adequately trained 4
• If intubation is necessary, ketamine with atropine premedication is suggested for sedation to maintain cardiovascular stability 4

Special Populations

• For pregnant women with dengue fever, acetaminophen remains the safest analgesic option 4, 5
• In children, acetaminophen dosing should be carefully calculated based on weight 4, 5
• Pregnant women with confirmed or suspected dengue should be hospitalized due to risk of maternal death, hemorrhage, preeclampsia, and vertical transmission 5

Discharge Criteria

Patients can be safely discharged when ALL of the following criteria are met 5:

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

Post-Discharge Instructions

• Monitor and record temperature twice daily after discharge 5
• Return immediately if temperature rises to ≥38°C on two consecutive readings or if any warning signs develop 5

Diagnostic Considerations

• Diagnosis is confirmed by PCR/NAAT on serum for patients with symptoms for 1-7 days, or IgM capture ELISA if symptoms present for more than 5-7 days 4, 5, 2
• For patients with possible exposure to both dengue and Zika virus, perform nucleic acid amplification tests on serum collected ≤7 days after symptom onset 5