What is the appropriate management for a patient suspected of having Dengue fever?

Management of Suspected Dengue Fever

All patients with clinically suspected dengue should receive immediate risk stratification 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 treatment should begin without waiting for diagnostic test results. 1

Immediate Clinical Assessment

Upon presentation, immediately evaluate for the following warning signs that indicate progression to severe disease 1, 2:

• High hematocrit with rapidly falling platelet count 1
• Severe abdominal pain or persistent vomiting 1
• Lethargy, restlessness, or altered mental status 1
• Mucosal bleeding 1
• Cold, clammy extremities (early shock) 1
• Narrow pulse pressure ≤20 mmHg or hypotension 2

Diagnostic Testing

For symptoms ≤7 days: Order dengue PCR/NAAT on serum as the preferred initial test 3, 2

For symptoms >7 days: Order IgM capture ELISA (MAC-ELISA) as the primary diagnostic test 2

Special consideration: In 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

Obtain daily complete blood count to track platelet counts and hematocrit levels, as these parameters guide fluid management and identify progression to severe disease 2, 4

Management Based on Risk Stratification

Dengue Without Warning Signs (Outpatient Management)

Aggressive oral hydration is the cornerstone of management with target fluid intake of 2,500-3,000 mL daily using any locally available fluids including water, oral rehydration solutions, cereal-based gruels, soup, and rice water 1, 4

Avoid soft drinks due to high osmolality 1, 4

Use acetaminophen (paracetamol) only for pain and fever management 2, 4

Never use aspirin or NSAIDs as they worsen bleeding tendencies 1, 4

Daily monitoring is essential during the critical phase (typically days 3-7 of illness) when plasma leakage can rapidly progress to shock 1, 4

Outpatient management is only appropriate if:

• No comorbidities (diabetes, hypertension, heart disease, immunocompromised state) 2
• Platelet count >100,000/mm³ without rapid decline 2
• Stable hematocrit without evidence of hemoconcentration 2
• Reliable daily follow-up available 2

Dengue With Warning Signs (Hospitalization Required)

Hospitalize immediately for close monitoring and IV fluid management 1, 2

Administer IV crystalloid fluids cautiously to maintain adequate perfusion while avoiding fluid overload 1

Monitor continuously for:

• Rising hematocrit (>20% increase from baseline) indicating ongoing plasma leakage 2
• Declining platelet count, particularly if ≤100,000/mm³ 2
• Signs of fluid overload: hepatomegaly, pulmonary rales, respiratory distress 4

Severe Dengue/Dengue Shock Syndrome (ICU Management)

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, 4

If shock persists after the first bolus, repeat crystalloid boluses up to a total of 40-60 mL/kg in the first hour before escalating therapy 1, 4

For severe shock with pulse pressure <10 mmHg, consider colloid solutions (dextran, gelafundin, or albumin) as moderate-quality evidence shows colloids achieve faster resolution of shock and require less total volume (mean 31.7 mL/kg versus 40.63 mL/kg for crystalloids) 4

Monitor for signs of adequate resuscitation:

• Normal capillary refill time 4
• Absence of skin mottling 4
• Warm and dry extremities 4
• Well-felt peripheral pulses 4
• Return to baseline mental status 4
• Adequate urine output (>0.5 mL/kg/hour in adults) 2, 4

For refractory shock despite adequate fluid resuscitation:

• Cold shock with hypotension: Titrate epinephrine as first-line vasopressor 4
• Warm shock with hypotension: Titrate norepinephrine as first-line vasopressor 4
• Target mean arterial pressure appropriate for age and maintain ScvO2 >70% 4

Blood transfusion may be necessary for significant bleeding, with target hemoglobin >10 g/dL if ScvO2 <70% 1, 4

Prophylactic platelet transfusion is not recommended 1, 5

Critical Pitfalls to Avoid

Delaying fluid resuscitation in established dengue shock syndrome significantly increases mortality—once hypotension occurs, cardiovascular collapse may rapidly follow 1, 4

Administering excessive fluid boluses in patients without shock leads to fluid overload and respiratory complications—avoid routine bolus IV fluids in patients with severe febrile illness who are not in shock 1, 4

Failing to recognize the critical phase (typically days 3-7 of illness) when plasma leakage can rapidly progress to shock 1, 4

Continuing aggressive fluid resuscitation once signs of fluid overload appear instead of switching to inotropic support—evidence shows aggressive shock management followed by judicious fluid removal decreased pediatric ICU mortality from 16.6% to 6.3% 1, 4

Using aspirin or NSAIDs when dengue cannot be excluded as they worsen bleeding tendencies 3, 1, 4

Special Populations

Pregnant women: Hospitalization is recommended for all pregnant women with confirmed or suspected dengue due to risk of maternal death, hemorrhage, preeclampsia, and vertical transmission 1, 2

Patients with comorbidities (diabetes with hypertension, heart disease, immunocompromised states) warrant hospitalization or very close outpatient monitoring as they have 2.16 times higher risk of dengue hemorrhagic fever 2

Patients older than 60 years have higher risk of complications and should be considered for hospitalization 2

Discharge Criteria

Patients can be safely discharged when ALL of the following criteria are met 2:

• Afebrile for ≥48 hours without antipyretics 2
• Resolution or significant improvement of symptoms 2
• Stable hemodynamic parameters for ≥24 hours without support 2
• Adequate oral intake 2
• Adequate urine output (>0.5 mL/kg/hour in adults) 2
• Laboratory parameters returning to normal ranges 2

Post-discharge instructions: Monitor temperature twice daily and return immediately if temperature rises to ≥38°C on two consecutive readings or if any warning signs develop 2