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Dengue Fever: Treatment & Medication

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

Treatment

Medical Care

  • Dengue fever is usually a self-limited illness, and only supportive care is required. Acetaminophen may be used to treat patients with symptomatic fever. Aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), and corticosteroids should be avoided.
  • 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 a rising hematocrit level or falling platelet count should have intravascular volume deficits replaced. Patients who improve can continue to be monitored in an outpatient setting. Patients who do not improve should be admitted to the hospital for continued hydration.
  • Patients who develop signs of dengue hemorrhagic fever warrant closer observation. Patients who develop signs of dehydration, such as tachycardia, prolonged capillary refill time, cool or mottled skin, diminished pulse amplitude, altered mental status, decreased urine output, rise in hematocrit levels, narrowed pulse pressure, or hypotension, require admission for intravenous fluid administration.
  • Successful management of severe dengue requires careful attention to fluid management and proactive treatment of hemorrhage. Intravascular volume deficits should be corrected with isotonic fluids such as Ringers 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, and, 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 recent study has suggested that starch may be preferable because of hypersensitivity reactions to dextran.35 If the patient does not improve after this, blood loss should be considered. Patients with internal or gastrointestinal bleeding may require transfusion. 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 level 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 recent case report demonstrated good improvement following intravenous anti-D globulin administration in two patients. The authors proposed that, similarly to nondengue forms of immune thrombocytopenic purpura, intravenous anti-D produces Fcγ receptor blockade to raise platelet counts.36
  • 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
    • Absence of respiratory distress
    • Platelet count greater than 50,000 cells/μL

Surgical Care

No specific surgical intervention is necessary in patients with dengue fever, dengue hemorrhagic fever, or dengue shock syndrome.

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.

Diet

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

Activity

Bedrest is recommended for patients with symptomatic dengue fever, dengue hemorrhagic fever, or dengue shock syndrome.

Medication

No specific antiviral medication currently is available to treat dengue infections. Single-dose methylprednisolone showed no mortality benefit in the treatment of dengue shock syndrome (dengue shock syndrome) in a prospective, randomized, double-blind, placebo-controlled trial.37

Acetaminophen (paracetamol) is recommended for treatment of pain and fever. Aspirin, other salicylates, and NSAIDs should be avoided.

Analgesics/antipyretics

The treatment of dengue fever is symptomatic and supportive in nature. Bedrest and mild analgesic-antipyretic therapy are often helpful in relieving lethargy, malaise, and fever associated with the disease.


Acetaminophen (Tylenol, Feverall)

Reduces fever by acting directly on hypothalamic heat-regulating centers, which increases dissipation of body heat via vasodilation and sweating. Used in dengue infections to relieve pain and lower temperature when fever is thought to contribute to patient discomfort.

Adult

325-650 mg PO/PR q4-6h or 1000 mg tid/qid; not to exceed 4 g/d

Pediatric

15 mg/kg PO/PR q4h prn; not to exceed 2.6 g/d

Rifampin can reduce analgesic effects; coadministration with barbiturates, carbamazepine, hydantoins, and isoniazid may increase hepatotoxicity; chronic use may potentiate effects of warfarin

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Hepatotoxicity possible in those with chronic alcoholism following various dose levels; severe or recurrent pain or high or continued fever may indicate a serious illness; APAP is contained in many OTC products, and combined use with these products may result in cumulative APAP doses that exceed recommended maximum dose

Volume expanders

Plasma volume expanders are used in the treatment of intravascular volume deficits or shock to restore intravascular volume, blood pressure, and tissue perfusion.


Lactated ringers with isotonic sodium chloride solution

Used to expand intravascular volume. Both fluids are essentially isotonic and have equivalent volume restorative properties. Although administration of large quantities of either fluid may lead to some differences in metabolic changes, for practical purposes and in most situations, these differences are clinically irrelevant. Importantly, no demonstrable difference in hemodynamic effect, morbidity, or mortality exists between resuscitation using either product.

Adult

10-20 mL/kg IV initially administered rapidly, over 20 min; followed by reassessment of hemodynamic response; repeat prn

Pediatric

Administer as in adults

Pulmonary edema (may lead to the development of ARDS)

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in CHF; caution admixing other agents (monitor for incompatibilities)


Dextran 40 (Macrodex, LMD)

Polymer of glucose. When infused, it increases intravascular volume, blood pressure, and capillary perfusion. Used to restore intravascular volume when isotonic crystalloid use fails.

Adult

Variable; not to exceed 20 mL/kg IV on d 1 or 10 mL/kg thereafter

Pediatric

Administer as in adults

Caution when administering parenteral fluids to patients receiving corticosteroids or corticotropin, especially if the solution contains sodium ions; can interfere with blood cross-matching and measuring serum glucose and bilirubin levels (draw blood for laboratory testing prior to administration)

Documented hypersensitivity; pulmonary edema

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

May cause nausea, which also may occur with hypoglycemia; IV dextrose solutions may result in dilution of serum electrolyte concentrations or overhydration in the setting of fluid overload; caution in patients experiencing congested states or pulmonary edema; hypertonic dextrose given peripherally may cause thrombosis (administer instead through central venous catheter); caution in subclinical diabetes mellitus or carbohydrate intolerance
Increased risk of inducing significant hyperglycemia or hyperosmolar syndrome if solution is administered rapidly, especially in patients with chronic uremia or carbohydrate intolerance; concentrated solutions should not be administered SC or IM; rates of dextrose infusion faster than 0.5 g/kg/h may produce glycosuria; at infusion rates of 0.8 g/kg/h, the incidence of glycosuria is 5%; closely monitor fluid balance, electrolyte concentrations, and acid-base balance; dextrose administration may produce vitamin B complex deficiency


Albumin (Albuminar-5, Buminate)

Human albumin is a sterile solution of albumin (major plasma protein responsible for colloid oncotic pressure of blood). Pooled from blood, serum, plasma, or placenta from healthy donors. Infusion of albumin results in a shift of fluid from extracellular space into circulation, thereby decreasing hemoconcentration and blood viscosity.
May be administered wide open when treating shock. Patient response must be assessed before repeating dose.

Adult

25 g IV; not to exceed 250 g/48 h

Pediatric

<37 weeks' gestation: 1 g/kg IV
Infants and children: 25-50% of adult dose IV

Documented hypersensitivity; pulmonary edema; protein load of 5% albumin

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in poor left ventricular systolic function (monitor central venous pressure during infusion)


Starch (hetastarch, 6% hydroxyethyl starch)

Hydroxyethyl starch is a sterile solution of starch responsible for colloid oncotic pressure of blood.
Infusion of albumin results in a shift of fluid from extracellular space into circulation, thereby decreasing hemoconcentration and blood viscosity.

Adult

May be administered in 6% solution, 15 mL/kg IV over 1 h; patient response must be assessed and then an additional dose of 10 mL/kg IV over 1 h may be administered

Pediatric

Administer as in adults

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in poor left ventricular systolic function (monitor central venous pressure during infusion)

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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