Dengue Fever Treatment
Dengue fever treatment is primarily supportive with aggressive oral hydration (>2500 mL daily), acetaminophen for symptom control, and careful monitoring for warning signs of severe disease—there is no specific antiviral therapy available. 1, 2, 3
Initial Assessment and Risk Stratification
Classify patients into three categories based on WHO criteria: dengue without warning signs, dengue with warning signs (persistent vomiting, severe abdominal pain, lethargy, mucosal bleeding, rising hematocrit with falling platelets), or severe dengue (shock, severe bleeding, organ failure). 2, 3, 4
Obtain daily complete blood counts to track platelet counts and hematocrit levels, which are essential for identifying progression to severe disease and guiding fluid management. 1, 2, 3
Confirm diagnosis with PCR/NAAT on serum if symptoms present for ≤7 days, or IgM capture ELISA if symptoms present for >7 days. 1, 2
Management of Uncomplicated Dengue (Without Warning Signs)
Ensure aggressive oral hydration with >2500 mL daily using any locally available fluids including water, oral rehydration solutions, cereal-based gruels, soup, or rice water—avoid soft drinks due to high osmolality. 1, 2, 3
Use acetaminophen at standard doses for fever and pain relief. 1, 2, 3
Never use aspirin or NSAIDs under any circumstances due to significantly increased bleeding risk in dengue patients. 1, 2, 3
Monitor daily for warning signs including persistent vomiting, severe abdominal pain, lethargy, restlessness, mucosal bleeding, and rising hematocrit with falling platelet count. 1, 2, 3
Management of Severe Dengue and Dengue Shock Syndrome
Immediate Fluid Resuscitation
Administer 20 mL/kg 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
Repeat crystalloid boluses up to 40-60 mL/kg in the first hour if shock persists, watching for signs of improvement in tachycardia, tachypnea, capillary refill, and mental status. 3
Consider colloid solutions (dextran, gelafundin, or albumin) for severe shock with pulse pressure <10 mmHg, as moderate-quality evidence shows colloids achieve faster resolution of shock (RR 1.09,95% CI 1.00-1.19) and require less total volume (mean 31.7 mL/kg versus 40.63 mL/kg for crystalloids). 3
Critical Monitoring During Resuscitation
Watch for signs of adequate tissue perfusion: normal capillary refill time, absence of skin mottling, warm and dry extremities, well-felt peripheral pulses, return to baseline mental status, and adequate urine output (>0.5 mL/kg/hour in adults). 3
Stop fluid resuscitation immediately if signs of fluid overload appear: hepatomegaly, pulmonary rales, or respiratory distress—switch to inotropic support rather than continuing fluid boluses. 3
Track hematocrit levels closely: rising hematocrit indicates ongoing plasma leakage requiring continued resuscitation, while falling hematocrit suggests successful plasma expansion. 3
Management of Refractory Shock
For cold shock with hypotension, titrate epinephrine as first-line vasopressor; for warm shock with hypotension, titrate norepinephrine as first-line vasopressor. 3
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
Target mean arterial pressure appropriate for age and maintain ScvO2 >70%. 3
Management of Complications
Blood transfusion may be necessary for significant bleeding or if hemoglobin <10 g/dL with ScvO2 <70%. 1, 2, 3
For persistent tissue hypoperfusion despite adequate fluid resuscitation, vasopressors such as dopamine or epinephrine may be required. 1, 2, 3
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%. 3
Consider continuous renal replacement therapy (CRRT) if fluid overload >10% develops, as outcomes are better when CRRT is initiated early. 3
Special Populations
Pregnant women with dengue require hospitalization due to risk of maternal death, hemorrhage, preeclampsia, and vertical transmission—acetaminophen remains the safest analgesic option. 2
In children, calculate acetaminophen dosing carefully based on weight and use the same aggressive fluid resuscitation protocol (20 mL/kg boluses), as proper fluid management achieves near 100% survival in pediatric dengue shock syndrome. 1, 3
Critical Pitfalls to Avoid
Never administer routine bolus IV fluids to patients with "severe febrile illness" who are NOT in shock, as this increases risk of fluid overload and respiratory complications without improving outcomes. 3
Do not delay fluid resuscitation in established dengue shock syndrome, as once hypotension occurs, cardiovascular collapse may rapidly follow—restrictive fluid strategies have no survival benefit and may worsen outcomes. 3
Do not continue aggressive fluid resuscitation once signs of fluid overload appear—this is the most critical error, as it can precipitate pulmonary edema and ARDS. 3
Avoid failing to recognize the critical phase (typically days 3-7 of illness) when plasma leakage can rapidly progress to shock. 3
Never prescribe antibiotics empirically for dengue fever without evidence of bacterial co-infection (occurs in <10% of cases), as this contributes to antimicrobial resistance without clinical benefit. 2
Discharge Criteria
Patients can be safely discharged when: afebrile for ≥48 hours without antipyretics, resolution or significant improvement of symptoms, stable hemodynamic parameters for ≥24 hours without support, adequate oral intake, adequate urine output (>0.5 mL/kg/hour in adults), and laboratory parameters returning to normal ranges. 2, 3
Instruct patients to monitor temperature twice daily and return immediately for temperature ≥38°C on two consecutive readings, persistent or recurrent vomiting, severe abdominal pain, lethargy, or any warning signs. 2