What is the primary treatment for a patient with dengue?

Treatment of Dengue

The primary treatment for dengue is aggressive oral hydration (2,500-3,000 mL daily) for non-severe cases and immediate fluid resuscitation with 20 mL/kg isotonic crystalloid boluses for dengue shock syndrome, as there is no specific antiviral therapy available. 1, 2

Initial Risk Stratification

Immediately classify patients into one of three categories that determines the entire management approach 2:

• Dengue without warning signs: Outpatient management with oral hydration
• Dengue with warning signs: Hospital admission with close monitoring
• Severe dengue/dengue shock syndrome: ICU admission with aggressive resuscitation

Warning signs requiring immediate escalation include high hematocrit with rapidly falling platelet count, severe abdominal pain, persistent vomiting, lethargy or restlessness, mucosal bleeding, and cold clammy extremities 2.

Management of Non-Severe Dengue

Oral Hydration Protocol

• Target 2,500-3,000 mL daily fluid intake (approximately 5 or more glasses throughout the day), which evidence demonstrates reduces hospitalization rates 3, 1
• Use any locally available fluids including water, oral rehydration solutions, cereal-based gruels, soup, and rice water 3, 2
• Avoid soft drinks due to high osmolality 3, 2

Symptomatic Management

• Use acetaminophen (paracetamol) only for pain and fever management 3, 1
• Strictly avoid aspirin and NSAIDs due to increased bleeding risk 1, 2
• Resume age-appropriate diet as soon as appetite returns 3

Monitoring Requirements

• Daily complete blood count to track platelet counts and hematocrit levels 1
• Watch for warning signs of progression during the critical phase (typically days 3-7 of illness) when plasma leakage can rapidly progress to shock 1, 2

Management of Dengue Shock Syndrome

Initial Fluid Resuscitation

Administer 20 mL/kg of isotonic crystalloid (Ringer's lactate or 0.9% normal saline) as a rapid bolus over 5-10 minutes 3, 1, 2. This aggressive initial approach achieves near 100% survival when properly administered 1.

• Reassess immediately after each bolus for signs of improvement (normal capillary refill, absence of skin mottling, warm dry extremities, well-felt peripheral pulses, return to baseline mental status, adequate urine output) 3, 1
• If shock persists, repeat crystalloid boluses up to 40-60 mL/kg total in the first hour before escalating therapy 3, 1, 2
• Moderate-quality evidence shows colloids provide 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), though clinical outcomes are similar 1

Management of Refractory Shock

Switch from aggressive fluid administration to inotropic support rather than continuing fluid boluses if shock persists despite 40-60 mL/kg in the first hour 3, 1. Delays in vasopressor therapy are associated with major increases in mortality 1.

• For cold shock with hypotension: titrate epinephrine as first-line vasopressor 3, 1
• For warm shock with hypotension: titrate norepinephrine as first-line vasopressor 3, 1
• Target mean arterial pressure appropriate for age and maintain ScvO2 >70% 1

Critical Monitoring During Resuscitation

• Stop fluid resuscitation immediately if hepatomegaly or pulmonary rales develop, signaling fluid overload 1
• Rising hematocrit indicates ongoing plasma leakage and need for continued resuscitation; falling hematocrit suggests successful plasma expansion 1
• In resource-rich settings with persistent shock, consider invasive monitoring to guide therapy 1

Management of Complications

Bleeding Management

• Blood transfusion may be necessary for significant bleeding 1, 2
• Target hemoglobin >10 g/dL if ScvO2 <70%, as oxygen delivery depends on hemoglobin concentration 3, 1
• Prophylactic platelet transfusion is not recommended 2

Post-Resuscitation Fluid Management

After initial shock reversal, judicious fluid removal may be necessary during the recovery phase, as evidence shows aggressive shock management followed by fluid removal decreased pediatric ICU mortality from 16.6% to 6.3% 1, 2. Consider continuous renal replacement therapy if fluid overload >10% develops 1.

Critical Pitfalls to Avoid

• 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
• 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 (hepatomegaly, rales, respiratory distress); switch to inotropic support instead 3, 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
• Restrictive fluid strategies have no survival benefit in dengue shock syndrome and may worsen outcomes 1

Special Populations

Pregnant Women

• Test by NAAT for both dengue and Zika virus, regardless of outbreak patterns, due to risk of maternal death, hemorrhage, preeclampsia, and vertical transmission 2
• Acetaminophen remains the safest analgesic option 2
• Hospitalization is recommended for all pregnant women with confirmed or suspected dengue 2