Dengue Fever Treatment
Dengue fever treatment is primarily supportive with aggressive oral hydration (targeting 2,500-3,000 mL daily), acetaminophen for symptom relief, and daily monitoring for warning signs, as no specific antiviral therapy exists. 1, 2, 3
Initial Risk Stratification
Immediately classify patients into one of three categories, as this determines the entire management approach 1, 2:
- Dengue without warning signs: Outpatient management with aggressive oral hydration
- Dengue with warning signs: Hospital admission for close monitoring
- Severe dengue: ICU admission with aggressive fluid resuscitation
Warning signs requiring immediate identification include 1, 2, 3:
- High hematocrit with rapidly falling platelet count
- Severe abdominal pain or persistent vomiting
- Lethargy, restlessness, or altered mental status
- Mucosal bleeding
- Cold, clammy extremities (early shock)
Outpatient Management (Dengue Without Warning Signs)
Aggressive oral hydration is the cornerstone of outpatient management, with target fluid intake of 2,500-3,000 mL daily using water, oral rehydration solutions, cereal-based gruels, soup, or rice water 1, 3. Avoid soft drinks due to high osmolality 3.
Pain and Fever Management
- Use acetaminophen (paracetamol) at standard doses for symptom relief 1, 3
- Never use aspirin or NSAIDs under any circumstances due to increased bleeding risk and worsening of bleeding tendencies 1, 2, 3
Monitoring Requirements
- Daily complete blood count monitoring to track platelet counts and hematocrit levels 1, 3
- Monitor for warning signs of progression to severe disease 1, 3
- Patients should monitor temperature twice daily after discharge 1
Discharge Criteria
Patients can be safely discharged when 1:
- Afebrile for ≥48 hours without antipyretics
- Resolution or significant improvement of symptoms
- Stable hemodynamic parameters for ≥24 hours without support
- Adequate oral intake and urine output (>0.5 mL/kg/hour in adults)
- Laboratory parameters returning to normal ranges
Hospital Management (Dengue With Warning Signs)
Hospitalize patients with 1:
- Rising hematocrit (>20% increase from baseline)
- Thrombocytopenia ≤100,000/mm³, particularly when declining rapidly
- Persistent vomiting or inability to tolerate oral fluids
- Pregnant women with confirmed or suspected dengue
Continue aggressive oral hydration if tolerated, but prepare for intravenous fluid therapy if clinical deterioration occurs 1, 3.
ICU Management (Severe Dengue/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 with immediate reassessment after each bolus 1, 2, 3. This aggressive initial fluid resuscitation demonstrates near 100% survival with appropriate fluid management 3.
If shock persists after the initial bolus 2, 3:
- Repeat crystalloid boluses up to a total of 40-60 mL/kg in the first hour before escalating therapy
- Reassess for signs of improvement: tachycardia and tachypnea improvement, warming of extremities, improved mental status
Colloid Solutions
For severe dengue shock with pulse pressure <10 mmHg or refractory shock, consider colloid solutions (dextran, gelafundin, or albumin) 1, 3. 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) 3.
Vasopressor Therapy
For persistent tissue hypoperfusion despite adequate fluid resuscitation 1, 3:
- Cold shock with hypotension: Titrate epinephrine as first-line vasopressor
- Warm shock with hypotension: Titrate norepinephrine as first-line vasopressor
- Target mean arterial pressure appropriate for age and maintain ScvO2 >70%
- Begin peripheral inotropic support immediately if central venous access is not readily available, as delays in vasopressor therapy are associated with major increases in mortality 3
Monitoring During Resuscitation
Watch for clinical indicators of adequate tissue perfusion 3:
- Normal capillary refill time
- Absence of skin mottling
- Warm and dry extremities
- Well-felt peripheral pulses
- Return to baseline mental status
- Adequate urine output
Stop fluid resuscitation immediately if hepatomegaly or pulmonary rales develop, as these signal fluid overload requiring switch to inotropic support 3.
Management of Complications
- Blood transfusion may be necessary for significant bleeding, with target hemoglobin >10 g/dL if ScvO2 <70% 1, 3
- Prophylactic platelet transfusion is not recommended 2
- 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% 2, 3
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 1, 2
- Acetaminophen remains the safest analgesic option 1, 2
- Hospitalize all pregnant women with confirmed or suspected dengue 1, 2
Children
- Acetaminophen dosing should be carefully calculated based on weight 1
- Use the same fluid resuscitation protocol (20 mL/kg boluses) with careful monitoring for fluid overload 3
Critical Pitfalls to Avoid
- Delaying fluid resuscitation in established dengue shock syndrome significantly increases mortality, as cardiovascular collapse may rapidly follow once hypotension occurs 2, 3
- Administering excessive fluid boluses in patients without shock leads to fluid overload and respiratory complications without improving outcomes 2, 3
- Failing to recognize the critical phase (typically days 3-7 of illness) when plasma leakage can rapidly progress to shock 2, 3
- Continuing aggressive fluid resuscitation once signs of fluid overload appear instead of switching to inotropic support 2, 3
- Prescribing antibiotics empirically without evidence of bacterial co-infection (occurs in <10% of cases) contributes to antimicrobial resistance without clinical benefit 1