Hospital Admission is Strongly Recommended
A 19-year-old male with leukemia in remission presenting with persistent fever despite paracetamol and a reactive Dengue NS1 test should be admitted for close monitoring and management. This patient represents a high-risk scenario requiring inpatient care due to his immunocompromised status from underlying hematological malignancy, even though he is in remission 1.
Rationale for Admission
Immunocompromised Status Takes Precedence
Patients with hematological malignancies and fever require prompt empirical antibacterial therapy and close monitoring, regardless of other diagnostic findings 1. The differential diagnosis for fever in this population remains broad, and dengue does not exclude concurrent bacterial infection.
The leukemia history, even in remission, places this patient at higher risk for severe infections and complications compared to immunocompetent dengue patients 1. Standard outpatient dengue management criteria do not apply to immunocompromised hosts.
Critical Caveat: NS1 Antigen False Positives in Hematological Malignancies
False-positive dengue NS1 antigen tests have been documented in patients with acute lymphoblastic leukemia, making the diagnosis uncertain 2. This case report demonstrates that NS1 reactivity alone cannot be relied upon in patients with hematological malignancies.
Confirmatory testing with dengue RT-PCR or IgM capture ELISA is essential before attributing all symptoms to dengue 3, 2. The NS1 test should guide initial suspicion but not definitive management decisions in this population.
Dengue-Specific Admission Criteria Also Support Hospitalization
Even if dengue is confirmed, this patient warrants admission based on:
Persistent fever despite antipyretics is a warning sign requiring close monitoring for progression to severe dengue 3, 4. Daily complete blood count monitoring to track platelet counts and hematocrit levels is essential 3, 4.
Patients with underlying conditions that increase bleeding risk should be hospitalized for observation during the critical phase (days 3-7 of illness) 3, 4.
Recommended Management Approach
Immediate Actions Upon Admission
Initiate empirical broad-spectrum antibacterial therapy immediately while awaiting culture results, as recommended for all febrile patients with hematological malignancies 1. The presence of dengue NS1 positivity does not exclude bacterial co-infection.
Obtain blood cultures, complete blood count with differential, comprehensive metabolic panel, and coagulation studies before starting antibiotics 1.
Send confirmatory dengue testing with RT-PCR (if within 7 days of symptom onset) or IgM capture ELISA (if >7 days) to verify the NS1 result 3, 4, 2.
Monitoring Protocol
Check vital signs every 4 hours, with continuous assessment for hemodynamic instability 3, 4. Monitor for warning signs including persistent vomiting, abdominal pain, lethargy, restlessness, and mucosal bleeding 3, 4.
Perform daily complete blood count to track platelet counts and hematocrit levels 3, 4. Rising hematocrit with falling platelet count indicates plasma leakage and progression to severe dengue.
Monitor for signs of hemophagocytic lymphohistiocytosis (HLH), a rare but serious complication of dengue that presents with persistent fever, hepatosplenomegaly, and cytopenias 5, 6. Check serum ferritin and triglycerides if fever persists beyond the expected dengue timeline.
Antimicrobial Management
Continue empirical antibiotics for at least 48-72 hours until blood cultures demonstrate no bacterial growth 1. Do not discontinue antibiotics based solely on positive dengue testing in an immunocompromised patient.
If vancomycin was added empirically, it may be stopped after 48 hours if blood cultures show no gram-positive organisms 1.
Avoid empirical antifungal therapy unless fever persists beyond 4-7 days despite appropriate antibacterial coverage 1.
Dengue-Specific Supportive Care
Use acetaminophen exclusively for fever control; strictly avoid NSAIDs and aspirin due to increased bleeding risk with both dengue and potential thrombocytopenia from leukemia 3, 4.
Ensure adequate oral hydration with target fluid intake exceeding 2500 mL daily if the patient can tolerate oral intake 3, 4.
Avoid prophylactic platelet transfusions unless active bleeding or invasive procedures are planned 1. Platelet transfusion thresholds in dengue with underlying hematological malignancy require individualized assessment.
Common Pitfalls to Avoid
Do not rely solely on NS1 antigen positivity to exclude bacterial infection in immunocompromised patients 2. The false-positive rate in hematological malignancies is unknown but documented.
Do not apply standard outpatient dengue management protocols to patients with underlying hematological malignancies 1, 3. These patients require inpatient monitoring regardless of dengue severity classification.
Do not discontinue antibiotics prematurely based on persistent fever alone if the patient is otherwise stable 1. Median time to defervescence in patients with hematological malignancies is 5 days with appropriate therapy.
Do not use growth factors (G-CSF) empirically in this setting, as they are not routinely indicated and may complicate management 1.
Discharge Criteria
The patient can be safely discharged only when all of the following criteria are met:
- Afebrile for ≥48 hours without antipyretics 3, 4
- Blood cultures negative for ≥48 hours 1
- Resolution or significant improvement of symptoms 3, 4
- Stable hemodynamic parameters for ≥24 hours without support 3, 4
- Platelet count stable or rising, hematocrit stable without evidence of hemoconcentration 3, 4
- Adequate oral intake and urine output (>0.5 mL/kg/hour) 3, 4
- Laboratory parameters returning toward normal ranges 3, 4