What is the best course of treatment for a 30-year-old male with dengue fever, presenting with danger signs and blurred vision?

Management of Dengue with Danger Signs and Blurred Vision

This 30-year-old male requires immediate hospitalization with aggressive fluid resuscitation for dengue shock syndrome while simultaneously obtaining urgent ophthalmology consultation for vision-threatening dengue maculopathy. 1, 2

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 with immediate reassessment after each bolus. 1, 2 The presence of "danger signs" indicates this patient is at high risk for progression to dengue shock syndrome, which has a mortality rate of 1-5% without proper management but can be reduced to <0.5% with appropriate clinical care. 2

Fluid Resuscitation Strategy

• If shock persists after the initial bolus, repeat crystalloid boluses up to a total of 40-60 mL/kg in the first hour before escalating therapy. 1, 2
• For severe shock with pulse pressure <10 mmHg, consider colloid solutions (gelafundin or albumin), 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
• Monitor for signs of adequate resuscitation: improvement in tachycardia and tachypnea, normal capillary refill time, warm and dry extremities, well-felt peripheral pulses, return to baseline mental status, and adequate urine output (>0.5 mL/kg/hour). 1

Critical Monitoring Parameters

• Obtain daily complete blood count to track platelet counts and hematocrit levels, as rising hematocrit indicates ongoing plasma leakage and need for continued resuscitation. 1, 3
• Watch for warning signs of fluid overload: hepatomegaly, pulmonary rales, or respiratory distress—if these develop, stop fluid resuscitation immediately and switch to inotropic support. 1, 2
• Monitor continuously with cardiac telemetry and pulse oximetry. 3

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
• Target mean arterial pressure appropriate for age and maintain ScvO2 >70%. 1

Management of Blurred Vision

Obtain urgent ophthalmology consultation for comprehensive fundoscopic examination to evaluate for dengue maculopathy, which can cause permanent visual impairment if not promptly recognized. 4, 5

Ocular Complications to Screen For

• Dengue maculopathy presents with dilated veins, hyperemic optic discs, flame and blot hemorrhages, soft exudates, and macular ischemia. 4
• Other vision-threatening complications include central retinal vein occlusion, acute macular neuroretinopathy, retinal vasculitis, and macular edema. 5, 6, 7
• The pathophysiology involves both bleeding tendency from thrombocytopenia and procoagulant state from immune reaction, creating risk for both hemorrhagic and thrombotic events. 6

Treatment of Dengue Maculopathy

High-dose corticosteroids may improve visual acuity and color vision in dengue maculopathy, though there is no definitive proven treatment. 4, 5 Despite lack of proven efficacy, corticosteroids have been used in vision-threatening dengue-related ocular complications. 5 Time for resolution ranges from 8 weeks to 4 months, with risk of residual visual impairment. 4

Supportive Care

• Use acetaminophen (paracetamol) only for pain and fever management. 1, 3
• Never use aspirin or NSAIDs under any circumstances due to high bleeding risk. 1, 2, 3
• Blood transfusion may be necessary for significant bleeding, with target hemoglobin >10 g/dL if ScvO2 <70%. 1, 2

Critical Pitfalls to Avoid

• Do not delay fluid resuscitation in established dengue shock syndrome, as cardiovascular collapse may rapidly follow once hypotension occurs. 1, 2
• Do not continue aggressive fluid resuscitation once signs of fluid overload appear—switch to inotropic support instead. 1, 2
• 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
• Do not fail to recognize the critical phase (typically days 3-7 of illness) when plasma leakage can rapidly progress to shock. 1, 2
• Do not overlook ocular complications—systematically screen for maculopathy when visual disturbances arise, as dengue fever should be suspected in travelers from endemic areas. 4, 5

Post-Resuscitation Management

After initial shock reversal, fluid removal may be necessary, as evidence shows aggressive shock management followed by judicious fluid removal decreased pediatric ICU mortality from 16.6% to 6.3%. 1, 2 Consider continuous renal replacement therapy (CRRT) if fluid overload >10% develops, as outcomes are better when CRRT is initiated early. 1