What are the treatment and management options for a patient suspected of having dengue?

Dengue Management

Immediate Risk Stratification

All patients with suspected dengue must be immediately classified into one of three categories—dengue without warning signs, dengue with warning signs, or severe dengue—as this classification determines the entire management approach and should not be delayed while awaiting diagnostic confirmation. 1

Warning Signs to Identify Immediately:

• Severe abdominal pain or persistent vomiting 1, 2
• Mucosal bleeding (gums, nose, vaginal bleeding) 1, 2
• Lethargy, restlessness, or altered mental status 1, 2
• Rising hematocrit (>20% increase) with rapidly falling platelet count 1, 2
• Cold, clammy extremities indicating early shock 1
• Clinical fluid accumulation (ascites, pleural effusion) 2
• Hepatomegaly 2

Severe Dengue Criteria (Requires ICU):

• Severe plasma leakage leading to shock or respiratory distress 2
• Severe bleeding requiring transfusion 1, 2
• Organ impairment (liver, CNS, heart) 2
• Dengue shock syndrome: hypotension or pulse pressure ≤20 mmHg 3

Diagnostic Testing

For patients presenting ≤7 days after symptom onset, dengue PCR/NAAT on serum is the preferred initial test; if negative or if presenting >7 days after onset, proceed to IgM capture ELISA. 4, 3

Testing Algorithm:

• Days 1-7 of illness: Dengue NAAT/PCR on serum 4, 3
• After day 7 or if NAAT negative: IgM antibody testing (MAC-ELISA) 4, 3
• Pregnant women: Test by NAAT for both dengue AND Zika virus regardless of outbreak patterns, plus concurrent IgM testing on serum and urine collected within 12 weeks of symptom onset 4, 1, 3
• Rapid diagnostic tests: NS1 antigen combined with IgG have very high positive likelihood ratios and can optimize management 3

Baseline Laboratory Assessment:

• Complete blood count with hematocrit and platelet count (repeat daily during critical phase days 3-7) 3, 2
• Liver function tests 2
• Coagulation profile if bleeding present 2
• Blood and urine cultures if fever persists beyond expected course 3, 2

Management by Disease Category

Dengue WITHOUT Warning Signs (Outpatient Management):

Aggressive oral hydration with target fluid intake of 2,500-3,000 mL daily using oral rehydration solutions or any locally available fluids except soft drinks is the cornerstone of outpatient management. 1, 3

• Acetaminophen at standard doses for fever and pain control 1, 3, 2
• Never use aspirin or NSAIDs due to increased bleeding risk and platelet dysfunction 1, 3, 2
• Daily monitoring for warning signs, particularly during critical phase (days 3-7) 3
• Patient education to return immediately if warning signs develop 1

Discharge criteria: Afebrile ≥48 hours without antipyretics, stable hemodynamics for ≥24 hours, adequate oral intake, urine output >0.5 mL/kg/hour, and laboratory parameters returning to normal 3, 2

Dengue WITH Warning Signs (Hospitalization Required):

Hospitalize all patients with warning signs to prevent progression to dengue shock syndrome through careful observation during the critical phase (days 3-7 of illness). 2

Fluid Management Strategy:

• Stable patients: Oral rehydration exceeding 2,500 mL daily using oral rehydration solutions 2
• Developing shock: Administer 20 mL/kg isotonic crystalloid bolus over 5-10 minutes 1, 2
• Reassess immediately after each bolus for signs of improvement 1, 2
• If shock persists, repeat crystalloid boluses up to 40-60 mL/kg in the first hour before escalating therapy 1
• Colloids achieve faster resolution of shock and require less total volume than crystalloids for severe cases 2

Monitoring:

• Daily complete blood count to track platelet counts and hematocrit 3
• Continuous assessment for progression to severe dengue 2
• Monitor for fluid overload complications 1

Severe Dengue/Dengue Shock Syndrome (ICU Management):

For established dengue shock syndrome, administer 20 mL/kg of isotonic crystalloid as a rapid bolus over 5-10 minutes with immediate reassessment after each bolus; delaying fluid resuscitation significantly increases mortality as cardiovascular collapse may rapidly follow once hypotension occurs. 1, 3

Aggressive Resuscitation Protocol:

• Initial bolus: 20 mL/kg isotonic crystalloid over 5-10 minutes 1, 3, 2
• Reassess immediately after first bolus 1, 3
• Repeat boluses up to 40-60 mL/kg in first hour if shock persists 1
• Consider colloid solutions for severe shock with pulse pressure <10 mmHg 3, 2

Vasopressor Support:

• Cold shock with hypotension: Epinephrine as first-line vasopressor 2
• Warm shock with hypotension: Norepinephrine 2
• Only initiate after adequate fluid resuscitation 2

Management of Bleeding:

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

Critical Transition Phase:

• After initial shock reversal, fluid removal may be necessary—evidence shows aggressive shock management followed by judicious fluid removal decreased pediatric ICU mortality from 16.6% to 6.3% 1
• Monitor for signs of fluid overload and switch to inotropic support rather than continuing aggressive fluids 1

Special Populations

Pregnant Women:

• Hospitalize all pregnant women with confirmed or suspected dengue due to risk of maternal death, hemorrhage, preeclampsia, and vertical transmission 1, 3
• Test by NAAT for both dengue AND Zika virus regardless of outbreak patterns 1, 3
• Acetaminophen remains the safest analgesic option 1, 3
• Consider alternative cooling measures (tepid water sponging) if fever recurs rather than increasing acetaminophen dose 3

Children:

• Acetaminophen dosing should be carefully calculated based on weight 3
• Same fluid management principles apply with weight-based calculations 1

Critical Pitfalls to Avoid

• Delaying fluid resuscitation in established dengue shock syndrome significantly increases mortality 1
• Administering excessive fluid boluses in patients without shock leads to fluid overload and respiratory complications 1
• Failing to recognize the critical phase (typically days 3-7 of illness) when plasma leakage can rapidly progress to shock 1
• Continuing aggressive fluid resuscitation once signs of fluid overload appear instead of switching to inotropic support 1
• Using aspirin or NSAIDs under any circumstances, which worsen bleeding tendencies 1, 3, 2
• Prescribing antibiotics empirically without evidence of bacterial co-infection, which contributes to antimicrobial resistance without clinical benefit (bacterial co-infection occurs in <10% of cases) 3
• Changing management based solely on persistent fever without clinical deterioration or new findings—fever typically resolves within 5 days 3

Post-Discharge Instructions

• Monitor and record temperature twice daily 3
• Return immediately if temperature rises to ≥38°C on two consecutive readings 3
• Return immediately for any warning signs: persistent vomiting, severe abdominal pain, mucosal bleeding, lethargy, cold extremities 1, 3
• Repeat complete blood count and liver function tests at 3-5 days post-discharge 3
• If transaminases were elevated 2-5× normal at discharge, monitor weekly until normalized 3
• If transaminases were >5× normal at discharge, monitor every 3 days initially 3

Prevention

• Day-biting mosquitoes of the genus Aedes, particularly Aedes aegypti, are the primary vectors 4, 3
• Meticulous avoidance of mosquito bites is essential 5
• Vaccination may be considered after documented initial infection 5