Dengue: Management

Overview

• Rosen's Emergency Medicine, p. 2630
• Harrison's Principles of Internal Medicine 22E, p. 5857

WHO Classification of Severity

• Park's Textbook of Preventive and Social Medicine, p. 295

Warning Signs (Require Hospital Admission)

• Abdominal pain or tenderness
• Persistent vomiting
• Clinical fluid accumulation (ascites, pleural effusion)
• Mucosal bleeding
• Lethargy or restlessness
• Liver enlargement >2 cm
• Rapid drop in platelet count with rising haematocrit
• Red Book 2021, p. 482

1. Dengue Fever (Outpatient Management)

• Encourage oral rehydration with ORS, fruit juice, or electrolyte-containing fluids
• Plain water alone is not preferable (use fluids with electrolytes and sugar); note that glucose-containing fluids may worsen hyperglycaemia in diabetics

• Paracetamol (acetaminophen) is the agent of choice - keep temperature <39°C; dosing interval must be ≥6 hours
• Avoid: Aspirin (risk of Reye's syndrome, bleeding), NSAIDs/ibuprofen (aggravate gastritis and bleeding tendency)

• Daily review: temperature pattern, fluid intake/output, urine frequency, platelet and haematocrit trends

• No clinical improvement, deterioration at defervescence, severe abdominal pain, persistent vomiting, cold/clammy extremities, lethargy, black stools or coffee-ground vomiting, no urine for >4-6 hours
• Park's Textbook of Preventive and Social Medicine, p. 294

2. Dengue with Warning Signs (Inpatient - DHF Febrile Phase)

• Management similar to DF with emphasis on close monitoring
• Paracetamol to keep temperature <39°C
• Oral fluids aggressively; IV fluids if persistent vomiting or refusal to feed
• Serial haematocrit monitoring from Day 3 onwards (daily until afebrile x 1-2 days) - haematocrit rise reflects degree of plasma leakage and guides IV fluid need
• The critical phase is the transition from febrile to afebrile stage (typically after Day 3); this is when shock risk is highest
• Park's Textbook of Preventive and Social Medicine, p. 295

3. DHF Grade I & II (Inpatient)

• IV crystalloids (normal saline or Ringer's lactate) guided by haematocrit
• Fluid resuscitation rate titrated to clinical response (urine output, pulse, BP, haematocrit)
• Avoid fluid overload; watch for pulmonary oedema
• Transfuse fresh blood or platelets only for significant clinical bleeding (not based on platelet count alone)

4. Severe Dengue - DHF Grade III & IV / Dengue Shock Syndrome

• Immediate IV fluid bolus (10-20 mL/kg of crystalloid) for shock
• Reassess frequently; adjust rate based on clinical improvement
• If no improvement: escalate to colloid solutions
• Blood transfusion for significant haemorrhage (packed red cells)
• Platelet transfusions generally reserved for active significant bleeding

• Manage acute kidney injury, hepatic injury, cardiac arrhythmias, and CNS complications as they arise
• ICU admission for DSS (Grade III/IV)

• Evaluated in several studies but evidence remains inconclusive; corticosteroids or chloroquine are not recommended
• Rosen's Emergency Medicine, p. 2630; Brenner and Rector's The Kidney

5. Platelet Transfusion - Key Points

• Not routinely indicated for thrombocytopenia alone
• Reserved for active significant bleeding or pre-procedure with very low counts
• Haematocrit and clinical signs are better guides than platelet count for fluid management

Disposition Summary

• Park's Textbook of Preventive and Social Medicine, p. 295
• Rosen's Emergency Medicine, p. 2630

Supportive Points

• No vaccine or antiviral is available for routine use in active disease management
• Vector control (reducing Aedes aegypti populations) remains the backbone of epidemic control
• Dengue is a reportable disease in most countries

Recent evidence note: A 2025 systematic review (PMID 41037858) on dengue pathogenesis, diagnosis, and management confirms the continued primacy of supportive care and reiterates absence of approved antivirals, consistent with the above textbook guidance.