What is the best management approach for a patient with dengue (Dengue virus infection), intestinal ileus, and normal hematocrit and platelet count, who is currently asymptomatic except for fever?

Management of Dengue with Intestinal Ileus and Normal Hematocrit/Platelets

This patient requires hospital admission for close monitoring despite normal hematocrit and platelets, as intestinal ileus represents a warning sign of severe dengue that can rapidly progress to shock. 1

Immediate Assessment and Risk Stratification

• Hospitalize immediately – intestinal ileus in dengue indicates potential plasma leakage and progression to severe disease, even with currently normal laboratory values 1, 2
• Obtain complete blood count with hematocrit and platelet monitoring at least twice daily during the critical phase (typically days 3-7 of illness) to detect rapid changes 1
• Perform abdominal ultrasound to evaluate for ascites, hepatomegaly, gallbladder wall thickening, and pleural effusions as evidence of plasma leakage 2
• Monitor vital signs every 2-4 hours, specifically watching for narrowing pulse pressure (≤20 mmHg), tachycardia, or hypotension 1

Fluid Management Strategy

• Initiate intravenous isotonic crystalloid fluids immediately due to ileus preventing adequate oral intake 3
• Start with maintenance rate of 2-3 mL/kg/hour, adjusting based on clinical response and hematocrit trends 1
• If hematocrit rises >20% from baseline or patient develops signs of shock (narrow pulse pressure, hypotension, altered mental status), administer 20 mL/kg crystalloid bolus over 5-10 minutes with immediate reassessment 1
• Avoid aggressive fluid boluses if patient remains hemodynamically stable, as overhydration can lead to pulmonary edema and pleural effusions 1

Management of Ileus

• Keep patient nil per os (NPO) until bowel sounds return and ileus resolves 3
• Insert nasogastric tube if significant abdominal distension or persistent vomiting occurs 3
• Obtain abdominal radiography to confirm ileus and rule out bowel obstruction or perforation 3
• Do not perform endoscopy or invasive abdominal procedures unless surgical emergency is suspected, as thrombocytopenia may develop rapidly 4

Pain and Fever Management

• Use acetaminophen (paracetamol) only at standard doses (650-1000 mg every 6 hours in adults) for fever and abdominal discomfort 1, 2
• Strictly avoid aspirin and NSAIDs due to bleeding risk, even with currently normal platelets 1, 5, 6
• Monitor QTc interval if anti-emetics are needed, as many prolong QT interval 3

Monitoring Parameters During Critical Phase

• Hematocrit every 6-12 hours – rising hematocrit (>20% increase) indicates plasma leakage even before shock develops 1
• Platelet count every 12-24 hours – rapid decline warrants more intensive monitoring 1
• Urine output hourly – target >0.5 mL/kg/hour as indicator of adequate perfusion 1
• Assess for warning signs every 4 hours: persistent vomiting, severe abdominal pain, lethargy, restlessness, mucosal bleeding, liver enlargement >2 cm 1, 2

Common Pitfalls to Avoid

• Do not dismiss normal hematocrit and platelets as reassuring – these can deteriorate rapidly during the critical phase, and ileus itself indicates disease progression 1
• Do not start empiric antibiotics – bacterial co-infection occurs in <10% of dengue cases, and empiric antibiotics contribute to resistance without benefit 1
• Do not perform surgical exploration for abdominal pain alone – dengue commonly presents with acute abdomen picture that resolves with conservative management 7
• Do not delay fluid resuscitation if shock develops – dengue shock syndrome requires immediate aggressive fluid therapy 1

Criteria for Escalation of Care

• Transfer to intensive care if pulse pressure ≤20 mmHg, systolic blood pressure <90 mmHg, altered mental status, or signs of organ dysfunction develop 1
• Consider colloid solutions (albumin, dextran) if severe shock with pulse pressure <10 mmHg persists despite crystalloid boluses 1
• Initiate vasopressors (dopamine or epinephrine) only if tissue hypoperfusion persists despite adequate fluid resuscitation 1

Discharge Criteria (Once Stabilized)

• Afebrile for ≥48 hours without antipyretics 1
• Resolution of ileus with return of bowel sounds and tolerance of oral intake 1
• Stable hemodynamic parameters for ≥24 hours without intravenous support 1
• Adequate urine output (>0.5 mL/kg/hour) 1
• Hematocrit stable without rising trend 1
• Platelet count improving or stable (not necessarily normalized) 1

Post-Discharge Instructions

• Monitor temperature twice daily, return if fever ≥38°C on two consecutive readings 1
• Return immediately for persistent vomiting, severe abdominal pain, bleeding (gums, nose, vomit, stool), lethargy, or restlessness 1, 2
• Repeat complete blood count in 3-5 days to ensure platelet recovery 1
• Maintain oral hydration of 2,500-3,000 mL daily during recovery phase 8