eMedicine Specialties > Infectious Diseases > Viral Infections

Dengue Fever: Follow-up

Author: Suzanne Moore Shepherd, MD, MS, DTM&H, FACEP, FAAEM, Associate Professor, Department of Emergency Medicine, Hospital of the University of Pennsylvania; Director of Education and Research, PENN Travel Medicine
Coauthor(s): Patrick B Hinfey, MD, Associate Residency Director, Department of Emergency Medicine, Newark Beth Israel Medical Center; William H Shoff, MD, DTM&H, Director, PENN Travel Medicine, Associate Professor, Department of Emergency Medicine, Hospital of the University of Pennsylvania
Contributor Information and Disclosures

Updated: Oct 23, 2009

Follow-up

Further Inpatient Care

  • Report known or suspected cases of dengue fever, dengue hemorrhagic fever, or dengue shock syndrome to public-health authorities. Such reports should include patient demographics, case classification, date of onset of illness, whether or not hospitalization was necessary, outcome, and recent travel history. When multiple patients are involved, reports should include the number of cases of dengue fever and dengue hemorrhagic fever/dengue shock syndrome stratified by age, number of confirmed cases and serotypes, and number of hospitalizations and deaths.
  • Draw serum specimens for diagnosis as soon as possible after the onset of illness or hospitalization and at the time of death or discharge from the hospital. Immediately place specimens on wet ice and send to the laboratory.
  • Evaluate and treat patients appropriately for other possible conditions until the diagnosis of dengue fever or dengue hemorrhagic fever/dengue shock syndrome is established.

Further Outpatient Care

  • Draw a serum specimen 7-21 days after the acute-phase serum specimen was drawn. Ideally, draw the convalescent-phase serum specimen 10 days after the acute-phase specimen. Immediately place the specimen on wet ice and send it to the laboratory.

Inpatient & Outpatient Medications

  • No specific medications are needed for patients with dengue fever or dengue hemorrhagic fever/dengue shock syndrome. In general, patients should continue to take any medications necessary for the treatment of other medical conditions. However, use diuretics, aspirin, NSAIDs, and antihypertensives with caution in patients with dengue hemorrhagic fever because these medications may exacerbate the pathophysiologic derangement associated with dengue hemorrhagic fever. Review the risks and benefits of each medication and decide on an individuals basis whether the medication should be continued.
  • The differential diagnoses of dengue fever and dengue hemorrhagic fever/dengue shock syndrome include many conditions that are treatable with specific medications, such as antibiotics. Until such conditions are excluded, they should be treated.

Transfer

  • Transfer patients with dengue fever or dengue hemorrhagic fever/dengue shock syndrome when necessary monitoring and treatment cannot be provided in the current unit or facility. Treat patients with dengue shock syndrome in intensive/critical care units.

Deterrence/Prevention

  • No vaccine is currently available for the prevention of dengue infection. Immunogenic, safe tetravalent vaccines have been developed and are undergoing clinical trials.38 Because immunity to a single dengue strain is the major risk factor for dengue hemorrhagic fever and dengue shock syndrome, a vaccine must provide high levels of immunity to all 4 dengue strains to be clinically useful.
  • The only way to prevent dengue virus acquisition is to avoid being bitten by a vector mosquito. This can be accomplished in several ways, as follows:
    • Avoid travel to areas where dengue is endemic. This is not an ideal strategy because it would require a person to avoid most tropical and subtropical regions of the world, and many of these regions are popular travel and work destinations.
    • Wear N,N-diethyl-3-methylbenzamide (DEET)–containing mosquito repellant.
    • Wear protective clothing, preferably impregnated with permethrin insecticide.
    • Remain in well-screened or air-conditioned places.
    • The use of mosquito netting is of limited benefit, as Aedes are day-biting mosquitoes.
    • Eliminate the mosquito vector using indoor sprays.
    • Eliminate the breeding ground of the mosquitoes by not allowing them access to small accumulations of stagnant water around human habitats. Such accumulations can be found in pots, old tires, or any vessel capable of holding water.
  • Support community-based vector control programs (including source reduction) and the use of vectoricidal agents, including predatory copepods as biological control agents.39,40,41,42

Complications

  • Neurologic manifestations such as seizures and encephalitis/encephalopathy have been reported in rare cases of dengue infection. Some of these cases did not manifest other typical features of dengue infection. Other neurological complications associated with dengue infection include neuropathies, Guillain-Barré syndrome, and transverse myelitis.
  • Liver failure has been associated with dengue hemorrhagic fever/dengue shock syndrome epidemics. Whether this is a viral effect or a product of prolonged liver hypoperfusion remains unclear.
  • Overhydration is a well-recognized complication of dengue fever and dengue hemorrhagic fever/dengue shock syndrome.
  • Dengue must be carefully differentiated from pre-eclampsia during pregnancy. An overlap of symptoms and signs, including thrombocytopenia, impaired liver function, capillary leak, ascites, and decreased urine output may make this clinically challenging. Definitive diagnosis is confirmed via serology. Pregnant women with dengue fever respond well to the usual therapy of fluids, rest, and antipyretics. If the mother acquires infection in the peripartum period, newborns should be evaluated for dengue with platelet counts and serologic studies.43,44

Prognosis

  • The prognosis of patients with dengue fever is excellent, with complete recovery being the norm. Patients with dengue hemorrhagic fever or dengue shock syndrome who do not die usually recover without sequelae. A 2005 review from Singapore of 14,209 patients found that useful predictors of death included atypical presentations, significant comorbid illness, abnormal serum markers (including albumin, PT, and PTT), and secondary bacterial infections.45

Patient Education

  • Educate patients, especially those who have experienced prior dengue fever, to avoid mosquito bites when traveling to dengue-endemic areas. Current evidence suggests that those with a history of dengue fever are at highest risk for dengue hemorrhagic fever or dengue shock syndrome if they are infected with a different dengue strain.

Miscellaneous

Medicolegal Pitfalls

  • Failure to suspect dengue infection in febrile patients with a history of travel to dengue endemic areas within 2 weeks of the onset of illness
  • Failure to suspect, identify, and treat other possible diseases such as meningitis or malaria
  • Failure to admit patients with signs and symptoms of intravascular volume loss for intravenous hydration
  • Failure to administer appropriate fluids to patients with dengue hemorrhagic fever or dengue shock syndrome
  • Failure to notify public health authorities about suspected cases of dengue infection

Special Concerns

  • Older patients, particularly those with congestive heart failure, must not be given excessive amounts of intravenous fluids.
  • Rare cases of vertical dengue transmission have been reported. Dengue should be suspected in pregnant patients with compatible clinical features. The potential for a neonate to be born with signs and symptoms of dengue fever should be anticipated.
 


More on Dengue Fever

Overview: Dengue Fever
Differential Diagnoses & Workup: Dengue Fever
Treatment & Medication: Dengue Fever
Follow-up: Dengue Fever
References
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Further Reading

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Keywords

dengue, dengue fever, breakbone fever, DF, dengue virus, dengue infection, dengue hemorrhagic fever, DHF, dengue shock syndrome, DSS, dengue virus 1, DENV-1, dengue virus 2, DENV-2, dengue virus 3, DENV-3, dengue virus 4, DENV-4, Flaviviridae, Flavivirus, Aedes aegypti, A aegypti, Aedes albopictus, A albopictus, mosquitoes, viral epidemic, epidemic, saddleback fever, epidemic dengue, hyperendemic dengue, breakbone fever, dengue hepatitis

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Contributor Information and Disclosures

Author

Suzanne Moore Shepherd, MD, MS, DTM&H, FACEP, FAAEM, Associate Professor, Department of Emergency Medicine, Hospital of the University of Pennsylvania; Director of Education and Research, PENN Travel Medicine
Suzanne Moore Shepherd, MD, MS, DTM&H, FACEP, FAAEM is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American Society of Tropical Medicine and Hygiene, International Society of Travel Medicine, Society for Academic Emergency Medicine, and Wilderness Medical Society
Disclosure: Nothing to disclose.

Coauthor(s)

Patrick B Hinfey, MD, Associate Residency Director, Department of Emergency Medicine, Newark Beth Israel Medical Center
Patrick B Hinfey, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, Emergency Medicine Residents Association, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

William H Shoff, MD, DTM&H, Director, PENN Travel Medicine, Associate Professor, Department of Emergency Medicine, Hospital of the University of Pennsylvania
William H Shoff, MD, DTM&H is a member of the following medical societies: American College of Physicians, American Society of Tropical Medicine and Hygiene, International Society of Travel Medicine, Society for Academic Emergency Medicine, and Wilderness Medical Society
Disclosure: Glaxo Smith Kline Consulting fee Consulting; Glaxo Smith Kline Honoraria Speaking and teaching

Medical Editor

Martin J Wood, MD †, Former Consulting Staff, Department of Infection and Tropical Medicine, Birmingham Heartlands Hospital, UK
Martin J Wood, MD † is a member of the following medical societies: Alliance for the Prudent Use of Antibiotics, American Society for Microbiology, Infectious Diseases Society of America, International Society for Infectious Diseases, and Royal College of Physicians
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Thomas M Kerkering, MD, Chief of Infectious Diseases, Virginia Tech, Carilion School of Medicine, Roanoke, Virginia
Thomas M Kerkering, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians, American Public Health Association, American Society for Microbiology, American Society of Tropical Medicine and Hygiene, Infectious Diseases Society of America, Medical Society of Virginia, and Wilderness Medical Society
Disclosure: Nothing to disclose.

CME Editor

Eleftherios Mylonakis, MD, Clinical and Research Fellow, Department of Internal Medicine, Division of Infectious Diseases, Massachusetts General Hospital
Eleftherios Mylonakis, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Physicians, American Society for Microbiology, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

Chief Editor

Burke A Cunha, MD, Professor of Medicine, State University of New York School of Medicine at Stony Brook; Chief, Infectious Disease Division, Winthrop-University Hospital
Burke A Cunha, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

 
 
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