What is the treatment for dengue?

Treatment of Dengue

Dengue treatment is primarily supportive with no specific antiviral therapy approved, focusing on careful fluid management tailored to disease severity—oral rehydration for uncomplicated cases and aggressive crystalloid resuscitation (20 mL/kg boluses) for dengue shock syndrome, while strictly avoiding NSAIDs and aspirin due to bleeding risk. 1

General Management Principles

Symptomatic Care

• Use acetaminophen (paracetamol) only for fever and pain control 1, 2
• Strictly avoid aspirin and NSAIDs as they significantly increase bleeding risk 1, 3
• No specific antiviral therapy is currently available or approved 1, 4

Monitoring Requirements

• Perform daily complete blood count monitoring, particularly tracking platelet counts and hematocrit levels 1
• Watch for warning signs of progression: persistent vomiting, severe abdominal pain, lethargy/restlessness, mucosal bleeding, and rising hematocrit with rapidly falling platelets 1, 2
• The critical phase typically occurs on days 3-7 of illness when plasma leakage can rapidly progress to shock 1, 3

Fluid Management by Disease Severity

Non-Shock Dengue (Dengue Without Warning Signs)

• Oral rehydration is the cornerstone of treatment for patients without shock 1, 2
• Target approximately 2,500-3,000 mL daily fluid intake, which evidence shows reduces hospitalization rates 1, 2
• Use any locally available fluids: water, oral rehydration solutions, cereal-based gruels, soup, rice water 1, 2
• Avoid soft drinks due to high osmolality 1, 2
• Critical pitfall: Do NOT give routine bolus IV fluids to patients with severe febrile illness who are not in shock, as this increases fluid overload and respiratory complications without improving outcomes 1, 2, 3

Dengue Shock Syndrome (Severe Dengue with Hypotension)

Initial Resuscitation Protocol

• Administer 20 mL/kg of isotonic crystalloid (0.9% normal saline or Ringer's lactate) as a rapid bolus over 5-10 minutes 1, 2, 3
• Immediately reassess after each bolus for signs of improvement: reduced tachycardia, improved capillary refill, warming of extremities, improved mental status 1, 2
• If shock persists, repeat crystalloid boluses up to a total of 40-60 mL/kg in the first hour before escalating therapy 1, 2
• Aggressive fluid management achieves near 100% survival when properly administered 1

Colloid Considerations

• Moderate-quality evidence shows colloids provide faster resolution of shock (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
• Consider colloids (dextran, gelafundin, or albumin) if shock persists after initial crystalloid resuscitation 1
• However, crystalloids remain first-line as clinical outcomes are ultimately similar 1

Monitoring During Resuscitation

• Target endpoints: normal capillary refill time, absence of skin mottling, warm and dry extremities, well-felt peripheral pulses, return to baseline mental status, adequate urine output 1, 2
• Rising hematocrit indicates ongoing plasma leakage and need for continued resuscitation 1, 2
• Stop fluid resuscitation immediately if hepatomegaly, pulmonary rales, or respiratory distress develop—these signal fluid overload requiring switch to inotropic support 1

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, 2
• For cold shock with hypotension: titrate epinephrine as first-line vasopressor 1, 2
• For warm shock with hypotension: titrate norepinephrine as first-line vasopressor 1, 2
• Target mean arterial pressure appropriate for age and maintain ScvO2 >70% 1
• Begin peripheral inotropic support immediately if central venous access is not readily available, as delays in vasopressor therapy significantly increase mortality 1

Post-Resuscitation Management

• After initial shock reversal, judicious fluid removal may be necessary 1
• Evidence shows aggressive shock management followed by careful 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 Complications

Bleeding

• Blood transfusion may be necessary in cases of significant bleeding 1, 2, 3
• Target hemoglobin >10 g/dL if ScvO2 <70% 1, 2
• Prophylactic platelet transfusion is not recommended 5

Organ Impairment

• Severe dengue may involve organ impairment requiring specific management 5
• Watch for secondary hemophagocytic lymphohistiocytosis, a potentially fatal complication that may require steroids or intravenous immunoglobulin 5

Critical Pitfalls to Avoid

1. Delaying fluid resuscitation in established dengue shock syndrome significantly increases mortality—once hypotension occurs, cardiovascular collapse may rapidly follow 1

2. Administering excessive fluid boluses in patients without shock leads to fluid overload and respiratory complications 1, 2, 3

3. Failing to recognize the critical phase (days 3-7) when plasma leakage can rapidly progress to shock 1, 3

4. Using aspirin or NSAIDs, which worsen bleeding tendencies 1, 2, 3

5. Continuing aggressive fluid resuscitation once signs of fluid overload appear—switch to inotropic support instead 1

6. Using restrictive fluid strategies in established dengue shock syndrome—moderate-quality evidence shows no survival benefit from colloid restriction, and restrictive fluids may worsen outcomes 1