Treating the Patient With Severe Dengue Infection
- Author: Daniel D Price, MD; Chief Editor: Barry E Brenner, MD, PhD, FACEP more...
Overview
Dengue has been called the most important mosquito-transmitted viral disease in terms of morbidity and mortality. Dengue fever is a benign, acute febrile syndrome occurring in tropical regions. In a small proportion of cases, the virus causes increased vascular permeability that leads to a bleeding diathesis or disseminated intravascular coagulation (DIC) known as dengue hemorrhagic fever (DHF). Secondary infection by a different dengue virus serotype has been confirmed as an important risk factor for the development of DHF.
In 20-30% of DHF cases, the patient develops shock, known as the dengue shock syndrome (DSS).
Worldwide, children younger than 15 years make up 90% of DHF cases.[1] In the Americas, however, DHF occurs in adults and children.
Dengue fever is not contagious through person-to-person contact.
Complications
Complications are rare but may include the following:
- Brain damage from prolonged shock or intracranial hemorrhage
- Myocarditis
- Encephalopathy
- Liver failure
Go to Dengue Infection, Pediatric Dengue, and Dermatologic Manifestations of Dengue for complete information on these topics.
Prehospital Care
Initiate supportive therapy as follows:
- Intravenous (IV) crystalloids, as needed to keep systolic blood pressure above 90 mm Hg
- Oxygen, empirically
Emergency Department Care
Continue supportive care by administering isotonic NS solution intravenously to maintain adequate blood pressure and adequate urine output of 0.5-1 mL/kg/h.
A bolus of 10-20 mL/kg every 30 minutes may be required to maintain blood pressure. A Foley catheter is helpful in monitoring urine output. The plasma leakage period is short (24-48 h), and intravenous fluids may be reduced if the patient maintains adequate oral hydration.
When the plasma leakage phase starts to resolve, the hematocrit level begins to fall, making identification of significant occult hemorrhage difficult. Administer blood transfusion if significant hemorrhage ensues (GI bleeding may be profound). Administer fresh frozen plasma or platelets if DIC is extensive and the patient is hemodynamically unstable. Prophylactic platelet transfusions in a stable thrombocytopenic patient are not needed.
Administer acetaminophen for fever control (not salicylates or ibuprofen, which can further hinder platelet function and increase bleeding complications). Glucocorticoids are not indicated.
Avoid procedures and treatments that may precipitate further bleeding, such as nasogastric tube placement or arterial punctures.
Corticosteroids are not helpful.
No antiviral therapy is available.
Inpatient Care
Admit the patient to the intensive care unit (ICU) if he or she is hypotensive or in DIC; otherwise, admit to medicine ward.
The patient may require a central line. An arterial line may be required. The patient may require blood components.
Prognosis
Morens states that the rapid clinical response to aggressive fluids and electrolytes in even moribund children with DHF/DSS "is among the most dramatic events in clinical medicine." Treated promptly, children in shock and coma can wake up and return to near normalcy within hours.[2]
Convalescence may be prolonged, with weakness and mental depression.
Continued bone pain, bradycardia, and premature ventricular contractions (PVCs) are common.
Survival is related directly to early hospitalization and aggressive supportive care.
Pediatric deaths associated with dengue viral infection most commonly occur in infants younger than 1 year.
Malavige GN, Fernando S, Fernando DJ, Seneviratne SL. Dengue viral infections. Postgrad Med J. Oct 2004;80(948):588-601. [Medline]. [Full Text].
Morens DM. Antibody-dependent enhancement of infection and the pathogenesis of viral disease. Clin Infect Dis. Sep 1994;19(3):500-12. [Medline].
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