What are the differences in treatment and management of dengue fever, Zika (Zika virus), and Chikungunya?

Contrasting Dengue, Zika, and Chikungunya: Treatment and Management Differences

Clinical Presentation Differences

All three arboviruses share overlapping symptoms (fever, rash, myalgia, arthralgia) but have distinct clinical features that guide management priorities. 1, 2

Dengue Fever

• Presents with fever, headache, retro-orbital pain, myalgia, arthralgia, and rash with 4-8 day incubation period 1, 3
• Critical distinguishing feature: Risk of progression to dengue hemorrhagic fever (DHF) or dengue shock syndrome (DSS) 1, 3
• Warning signs include persistent vomiting, severe abdominal pain, lethargy, restlessness, mucosal bleeding, and rising hematocrit with falling platelet count 1, 3

Zika Virus

• Characterized by pruritic rash, low-grade fever, and arthralgia 4
• Most critical concern: Congenital nervous system malformations when infection occurs during pregnancy 5, 4
• Generally milder clinical course compared to dengue 6

Chikungunya

• Distinctive dermatologic manifestations include facial melanosis and bullous eruption 4
• Prolonged arthralgia is characteristic 2, 6
• Does not typically cause hemorrhagic complications like dengue 4

Diagnostic Approach Differences

For symptomatic nonpregnant persons, dengue and Zika virus NAATs should be performed on serum collected ≤7 days after symptom onset 5

Testing Timeline

• IgM antibody testing should be performed on NAAT-negative serum specimens or serum collected >7 days after onset of symptoms 5, 1
• For symptomatic pregnant women, serum and urine specimens should be collected as soon as possible within 12 weeks of symptom onset for concurrent dengue and Zika virus NAATs and IgM antibody testing 5

Cross-Reactivity Challenge

• IgM antibody testing is complicated by cross-reactivity between dengue and Zika viruses, which may preclude conclusive determination of which virus caused the infection 5
• Positive IgM antibody test results with negative NAAT results should be confirmed by neutralizing antibody tests when clinically or epidemiologically indicated, including for all pregnant women 5

Treatment and Management Differences

Dengue-Specific Management

Acetaminophen at standard doses is the ONLY recommended analgesic for dengue fever 1, 7

Critical Medication Restrictions

• Aspirin and NSAIDs must be avoided due to increased bleeding risk with thrombocytopenia 1, 7, 3
• This is the most important treatment distinction from other febrile illnesses 1

Monitoring Requirements

• Daily complete blood count monitoring is essential to track platelet counts and hematocrit levels 1, 3
• Monitor for rising hematocrit (>20% increase from baseline) with falling platelet counts 7, 3

Fluid Management for Dengue Shock

• For patients with dengue shock syndrome, administer an initial fluid bolus of 20 mL/kg over 5-10 minutes with careful reassessment 1, 3
• Consider colloid solutions for severe shock when available 3
• Avoid excessive fluid boluses in patients without shock to prevent fluid overload and respiratory complications 1

Hospitalization Criteria

• Admit patients with persistent vomiting preventing adequate oral hydration, rapidly decreasing platelet count, rising hematocrit with falling platelets, or any warning signs of severe dengue 7, 3
• Pregnant women with confirmed or suspected dengue should be hospitalized due to risk of maternal death, hemorrhage, and preeclampsia 3

Zika-Specific Management

The primary management focus for Zika is identifying and monitoring pregnant women due to risk of congenital malformations 5, 8

Pregnancy Considerations

• Test pregnant women by NAAT for both dengue and Zika viruses regardless of outbreak patterns due to possible adverse outcomes 1, 3
• Women with laboratory evidence of possible Zika virus infection during pregnancy and their infants should be evaluated and managed for possible adverse outcomes 5
• Acetaminophen remains the safest analgesic option in pregnancy 1, 7

Transmission Precautions

• Probable human-to-human transmission through exchange of body fluids, including sexual and perinatal transmission and through blood transfusion, makes containment more challenging 8

Chikungunya Management

• Supportive care with acetaminophen for symptom relief 1
• No specific hemorrhagic or shock complications requiring intensive monitoring like dengue 4
• Management of prolonged arthralgia may be necessary 2, 6

Common Pitfalls to Avoid

Never use aspirin or NSAIDs when dengue cannot be excluded 1, 3

• Do not delay fluid resuscitation in patients showing signs of dengue shock 1, 3
• Do not change antibiotics or management based solely on persistent fever pattern without clinical deterioration or new findings 3
• Avoid diagnosing based on symptoms alone given significant clinical overlap between all three viruses 2, 6, 9

Reporting Requirements

Dengue and Zika virus disease are nationally notifiable conditions, and cases should be reported to public health authorities 5