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Dengue Treatment & Management

  • Author: Suzanne Moore Shepherd, MD, MS, DTM&H, FACEP, FAAEM; Chief Editor: Michael Stuart Bronze, MD  more...
 
Updated: Oct 05, 2015
 

Approach Considerations

Dengue fever is usually a self-limited illness. There is no specific antiviral treatment currently available for dengue fever. The World Health Organization (WHO) has provided a number of free publications about dengue.

Supportive care with analgesics, fluid replacement, and bed rest is usually sufficient. Acetaminophen may be used to treat fever and relieve other symptoms. Aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), and corticosteroids should be avoided. Management of severe dengue requires careful attention to fluid management and proactive treatment of hemorrhage.

Single-dose methylprednisolone showed no mortality benefit in the treatment of dengue shock syndrome in a prospective, randomized, double-blind, placebo-controlled trial.[63] The Novartis Institute for Tropical Diseases (NITD) in Singapore is carrying out research to find inhibitors of dengue viral target proteins to reduce the viral load during active infection.[64]

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Suspected Dengue

Oral rehydration therapy is recommended for patients with moderate dehydration caused by high fever and vomiting. Patients with known or suspected dengue fever should have their platelet count and hematocrit measured daily from the third day of illness until 1-2 days after defervescence. Patients with clinical signs of dehydration and patients with a rising hematocrit level or falling platelet count should have intravascular volume deficits replaced under close observation. Those who improve can continue to be monitored in an outpatient setting, and those who do not improve should be admitted to the hospital for continued hydration.

Patients who develop signs of dengue hemorrhagic fever warrant closer observation. Admission for intravenous fluid administration is indicated for patients who develop signs of dehydration, such as the following:

  • Tachycardia
  • Prolonged capillary refill time
  • Cool or mottled skin
  • Diminished pulse amplitude
  • Altered mental status
  • Decreased urine output
  • Rising hematocrit
  • Narrowed pulse pressure
  • Hypotension
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Severe Dengue

Successful management of severe dengue requires careful attention to fluid management and proactive treatment of hemorrhage. Admission to an intensive care unit is indicated for patients with dengue shock syndrome.

Patients may need a central intravenous line for volume replacement and an arterial line for accurate blood pressure monitoring and frequent blood tests. Exercise caution when placing intravascular catheters because of the increased bleeding complications of dengue hemorrhagic fever. Urethral catheterization may be useful to strictly monitor urine output.

Intravascular volume deficits should be corrected with isotonic fluids such as Ringer lactate solution. Boluses of 10-20 mL/kg should be given over 20 minutes and may be repeated. If this fails to correct the deficit, the hematocrit value should be determined. If it is rising, limited clinical information suggests that a plasma expander may be administered. Starch, dextran 40, or albumin 5% at a dose of 10-20 mL/kg may be used. One study has suggested that starch may be preferable because of hypersensitivity reactions to dextran.[65]

If the patient does not improve after infusion of a plasma expander, blood loss should be considered. Patients with internal or gastrointestinal bleeding may require transfusion, and patients with coagulopathy may require fresh frozen plasma.

After patients with dehydration are stabilized, they usually require intravenous fluids for no more than 24-48 hours. Intravenous fluids should be stopped when the hematocrit falls below 40% and adequate intravascular volume is present. At this time, patients reabsorb extravasated fluid and are at risk for volume overload if intravenous fluids are continued. Do not interpret a falling hematocrit value in a clinically improving patient as a sign of internal bleeding.

Platelet and fresh frozen plasma transfusions may be required to control severe bleeding. A case report demonstrated good improvement following intravenous anti-D globulin administration in 2 patients. The authors proposed that, as in immune thrombocytopenic purpura from disorders other than dengue, intravenous anti-D produces Fcγ receptor blockade to raise platelet counts.[66]

Patients who are resuscitated from shock rapidly recover. Patients with dengue hemorrhagic fever or dengue shock syndrome may be discharged from the hospital when they meet the following criteria:

  • Afebrile for 24 hours without antipyretics
  • Good appetite, clinically improved condition
  • Adequate urine output
  • Stable hematocrit level
  • At least 48 hours since recovery from shock
  • No respiratory distress
  • Platelet count greater than 50,000 cells/μL

Pregnant patients

Dengue in pregnancy must be carefully differentiated from preeclampsia. An overlap of signs and symptoms, including thrombocytopenia, capillary leak, impaired liver function, ascites, and decreased urine output may make this clinically challenging. Pregnant women with dengue fever respond well to the usual therapy of fluids, rest, and antipyretics. However, 3 cases of maternal death due to dengue fever in the third trimester have been reported. An awareness of the clinical and laboratory manifestations of dengue in pregnancy should allow its early recognition and the institution of appropriate treatment. If the mother acquires infection in the peripartum period, newborns should be evaluated for dengue with serial platelet counts and serological studies.[67, 68]

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Diet and Activity

No specific diet is necessary for patients with dengue fever. Patients who are able to tolerate oral fluids should be encouraged to drink oral rehydration solution, fruit juice, or water to prevent dehydration from fever, lack of oral intake, or vomiting. Return of appetite after dengue hemorrhagic fever or dengue shock syndrome is a sign of recovery.

Bed rest is recommended for patients with symptomatic dengue fever, dengue hemorrhagic fever, or dengue shock syndrome. Permit the patient to gradually resume their previous activities, especially during the long period of convalescence.

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Prevention

The only way to prevent dengue virus acquisition is to avoid being bitten by a vector mosquito. Although this can be accomplished by avoiding travel to areas where dengue is endemic, that is not an ideal strategy because it would require a person to avoid most tropical and subtropical regions of the world, many of which are popular travel and work destinations. Other measures are as follows:

  • 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

The most widely used mosquito-control technique, spraying cities to kill adult mosquitoes, is not effective. Efforts should target the larval phase with larvicides and cleaning up larvae habitats. Poor sanitation and poor refuse control provide excellent conditions for mosquito larvae to grow. Hurricanes and other natural disasters increase the habitat for mosquito growth in urban areas by increasing rubble and garbage, which act as water reservoirs.

Breeding of vector mosquitoes can be reduced by eliminating small accumulations of stagnant water around human habitats (eg, disposing of old tires, covering water receptacles, and changing water in birdbaths daily. Support community-based vector control programs (including source reduction) and the use of vectoricidal agents, including predatory copepods as biological control agents.[69, 70, 71, 72]

Outbreaks of dengue will increasingly cross common borders of endemic and disease-free countries unless the following measures are undertaken:

  • Increased health surveillance
  • Prompt reporting of new cases
  • Heightened professional awareness
  • Public education
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Vaccine Development

No vaccine is currently approved for the prevention of dengue infection. 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.[73]

Immunogenic, safe tetravalent vaccines have been developed and are undergoing clinical trials.[74] Candidate vaccines include a live-attenuated virus, recombinant envelope proteins, and an inactivated virus.[75, 76, 77] The estimates of the time needed for further testing of candidate vaccines range from 5-10 years. Sanofi Pasteur has reported successful results of phase II trials of its tetravalent recombinant live attenuated vaccine.[78, 79] Registration is anticipated in 2012.

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Consultations

Consultation with an infectious diseases specialist may be helpful in guiding decisions regarding diagnosis and treatment. Consultation with a critical care medicine specialist may be helpful when treating patients with dengue hemorrhagic fever or dengue shock syndrome and severe hemorrhagic manifestations or shock.

Telephone consultation may be obtained from the Centers for Disease Control and Surveillance (800-232-4636, 8am-8pm ET/Monday-Friday).

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Contributor Information and Disclosures
Author

Suzanne Moore Shepherd, MD, MS, DTM&H, FACEP, FAAEM Professor of Emergency Medicine, Education Officer, Department of Emergency Medicine, Hospital of the University of Pennsylvania; Director of Education and Research, PENN Travel Medicine; Medical Director, Fast Track, Department of Emergency 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, Wilderness Medical Society

Disclosure: Nothing to disclose.

Coauthor(s)

Patrick B Hinfey, MD Emergency Medicine Residency Director, Department of Emergency Medicine, Newark Beth Israel Medical Center; Clinical Assistant Professor of Emergency Medicine, New York College of Osteopathic Medicine

Patrick B Hinfey, MD is a member of the following medical societies: American Academy of Emergency Medicine, Wilderness Medical Society, American College of Emergency Physicians, 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, University of Pennsylvania School of Medicine

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, Wilderness Medical Society

Disclosure: Nothing to disclose.

Chief Editor

Michael Stuart Bronze, MD David Ross Boyd Professor and Chairman, Department of Medicine, Stewart G Wolf Endowed Chair in Internal Medicine, Department of Medicine, University of Oklahoma Health Science Center; Master of the American College of Physicians; Fellow, Infectious Diseases Society of America

Michael Stuart Bronze, MD is a member of the following medical societies: Alpha Omega Alpha, American Medical Association, Oklahoma State Medical Association, Southern Society for Clinical Investigation, Association of Professors of Medicine, American College of Physicians, Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Acknowledgements

Joseph Domachowske, MD Professor of Pediatrics, Microbiology and Immunology, Department of Pediatrics, Division of Infectious Diseases, State University of New York Upstate Medical University

Joseph Domachowske, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American Society for Microbiology, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, and Phi Beta Kappa

Disclosure: Nothing to disclose.

Hagop A Isnar, MD, FACEP Department of Emergency Medicine, Crouse Hospital

Hagop A Isnar, MD, FACEP is a member of the following medical societies: American College of Emergency Physicians, American Medical Association, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

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.

Deborah Sentochnik, MD Consulting Staff, Department of Internal Medicine, Division of Infectious Disease, The Mary Imogene Bassett Hospital

Deborah Sentochnik, MD is a member of the following medical societies: American College of Physicians, Infectious Diseases Society of America, and Medical Society of the State of New York

Disclosure: Nothing to disclose.

Russell W Steele, MD Head, Division of Pediatric Infectious Diseases, Ochsner Children's Health Center; Clinical Professor, Department of Pediatrics, Tulane University School of Medicine

Russell W Steele, MD is a member of the following medical societies: American Academy of Pediatrics, American Association of Immunologists, American Pediatric Society, American Society for Microbiology, Infectious Diseases Society of America, Louisiana State Medical Society, Pediatric Infectious Diseases Society, Society for Pediatric Research, and Southern Medical Association

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Reference Salary Employment

Mary L Windle, PharmD, Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

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Drawing of Aedes aegypti mosquito. Picture from the Centers for Disease Control and Prevention (CDC) Web site.
Aedes aegypti mosquito. Picture from the Centers for Disease Control and Prevention (CDC) Web site.
Aedes albopictus. From CDC Public Domain.
Worldwide distribution of dengue in 2000. Picture from the Centers for Disease Control and Prevention (CDC) Web site.
Worldwide distribution of dengue in 2003. Picture from the Centers for Disease Control and Prevention (CDC) Web site.
Worldwide distribution of dengue in 2005. Picture from the Centers for Disease Control and Prevention (CDC) Web site.
Increasing rates of dengue infection by regions of the world. Graphs from the World Health Organization (WHO) Web site.
Dengue transmission cycle. Illustration from the Centers for Disease Control and Prevention (CDC) Web site.
Reinfestation by Aedes aegypti in the Americas after the 1970 (left) mosquito eradication program and most recent distribution as of 2002 (right). Picture from the Centers for Disease Control and Prevention (CDC) Web site.
A child with dengue hemorrhagic fever or dengue shock syndrome may present severely hypotensive with disseminated intravascular coagulation (DIC), as this severely ill pediatric ICU patient did. Crystalloid fluid resuscitation and standard DIC treatment are critical to the child's survival.
Delayed capillary refill may be the first sign of intravascular volume depletion. Hypotension usually is a late sign in children. This child's capillary refill at 6 seconds was delayed well beyond a normal duration of 2 seconds.
Signs of early coagulopathy may be as subtle as a guaiac test that is positive for occult blood in the stool. This test should be performed on all patients in whom dengue virus infection is suspected.
 
 
 
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