1. Dengue fever –
practice parameters

2. Dengue fever management
The first principle…..
Dengue virus infection has no specific
therapy

3. Dengue fever management
Why should I know about
dengue management
 Case fatality rate of dengue hemorrhagic
fever in most countries is 5 %
 Most fatal cases are among children and
young adults

4. Dengue fever management
Why should I know about
dengue management
 Most important mosquito-borne viral disease
of humans
 Global distribution comparable to malaria
 2.5 billion people live in areas at risk for
epidemic transmission
 Annually tens of millions of dengue fever and
hundreds of thousands of dengue
hemorrhagic fever occur

5. Dengue fever management
Illustrative case scenario
 Master Rahul is a three-year-old boy who
presented with fever since 3 days
 His intake was poor and he had vomited
twice on the day he presented
 He was febrile when seen
 He was given amoxycillin (Mox kid DT),
mefenemic acid (Ponstan) and B-complex
syrup

6. Dengue fever management
Case vignette
 No diagnosis was attempted
 Blanket therapy in blinded manner
 He was ‘listless’ next day
 Seen by another pediatrician and admitted

7. Dengue fever management
Course…
 Treated with antimalarial therapy and
ceftrioxone (presumably for enteric fever)
 Leukopenia warranted consideration of
typhoid
 Elevated transaminases considered as
‘malarial versus enteric hepatitis’

8. Dengue fever management
Case vignette – tests
 Blood culture negative, tests for malaria and
leptospira negative
 Serology for dengue - positive

9. Dengue fever management
First principle
 Fever and constitutional symptoms in any
patient-consider dengue in the differential
 Exclude other treatable diseases that mimic
dengue like malaria, leptospira and enteric
fever

10. Dengue fever management
Therapeutic strategies
 Symptomatic therapy
 Supportive therapy
 Specific therapy
 Preventive therapy

11. Dengue fever management
Management options
 No specific therapy
 Treatment is essentially supportive

12. Dengue fever management
Symptomatic management
 Avoid dehydration
 Adequate oral hydration and intake
 Paracetamol for fever and myalgia
 Avoid aspirin and NSAIDs – to avoid gastric
bleed and Reye’s syndrome
 Evaluate for impending complications, such
as early evidence of dengue hemorrhagic
fever

13. Dengue fever management
Management hierarchy
 No hemorrhagic manifestations and patient is
well-hydrated: home treatment
 Hemorrhagic manifestations or hydration
borderline: outpatient observation center or
hospitalization
 Warning signs (even without profound shock)
or DSS: hospitalize

14. Dengue fever management
Out patient management
 Paracetamol
 Hydration
 Rest
 Instruction regarding danger signs
 Repeated clinical evaluation
 Bare minimum tests: HCt, Platelet count,
AST

15. Dengue fever management
Danger Signs
 Abdominal pain - intense and sustained
 Persistent vomiting
 Abrupt change from fever to hypothermia,
with sweating and prostration
 Restlessness or somnolence

16. Dengue fever management
Follow up for outpatients
 For patients with bleeding manifestations
Serial HCt and platelets at least daily until
temperature is normal for 1 to 2 days

17. Dengue fever management
When to admit
 BP < 90/60 mm Hg
 HCt > 50 %
 Platelets < 50,000/cu.mm
 Bleeding other than petechiae
 When danger signs develop

18. Dengue fever management
Case vignette - course
 Master Rahul was severely dehydrated
warranting admission
 Fortunately dehydration detected early

19. Dengue fever management
 Management of dehydration in dengue

20. Dengue fever management
I.V Fluids for Moderate
Dehydration
 <7 kg 220 ml/kg/d
 7 – 11 kg 165 ml/kg/d
 12 – 18 kg 132 ml/kg/d
 19 – 40 kg 88 ml/kg/d

21. Dengue fever management
Case vignette management
 Master Rahul was 18 kg
 Treated with 18 x 132 = 2356 ml, ie. 100
ml/hour RL solution

22. Dengue fever management
Rehydrating Patients > 40 kg
 Volume required for rehydration is twice the
recommended maintenance requirement
 Formula for calculating maintenance volume:
1500 + 20 x (weight in kg - 20)
 For example, maintenance volume for 55 kg
patient is: 1500 + 20 x (55-20) = 2200 ml
 For this patient, the rehydration volume would be
2 x 2200, or 4400 ml

23. Dengue fever management
 Avoid invasive procedures when possible
 Shock requires ICU treatment

24. Dengue fever management
Treatment of shock – WHO
guidelines
 Initial bolus of 5 % DNS or RL(10 to 20 mL
per kg) infused rapidly
 Followed by continuous infusion (10 to 20
mL/kg per hour)
 Continue until vital signs and urine output
normalize
 Infusion rate then gradually reduced until it
matches plasma fluid losses

25. Dengue fever management
Management pearls
 Adequacy of fluid repletion: Serial HCt, BP, pulse,
and urine output
 Shock on presentation: Vital signs every 30 minutes
and HCt every 2–4 hours
 Narrowing of pulse pressure an indication of
hypovolemia in children even with a normal systolic
BP
 Normalization of HCt is an important goal of early
fluid repletion; however, a normal or low HCt may be
misleading in patients with overt bleeding and
severe hypovolemia

26. Dengue fever management
Keep vigil….
 Close clinical observation even after normal blood
volume is restored, because patients can develop
shock for one to two days after initial fluid
resuscitation which represents the period of
increased vascular permeability in DHF
 Most who present for medical attention before
profound shock develops and who receive
appropriate fluid therapy will recover quickly

27. Dengue fever management
Do not overdo things … !
 Fluids lost into tissue spaces during the period of
plasma leakage rapidly reabsorbed
 So i.v fluid supplementation to be discontinued once
patients take oral fluids and have normal HCt, vital
signs, and urine output
 Usually < 48 hours of i.v fluids needed
 Excessive fluid administration after this point can
precipitate hypervolemia and pulmonary edema

28. Dengue fever management
 Master Rahul was followed up with serial HCt
and platelets
 Developed melena
 Had coffee ground vomitus once

29. Dengue fever management
 Management of bleeding complications

30. Dengue fever management
Significant bleeding
 Gastrointestinal bleeding or menorrhagia can
be severe enough to require blood
transfusion.
 Factors that contribute to bleeding:
thrombocytopenia due to decreased platelet
survival, DIC
 Platelet transfusions rarely given, warranted
with severe thrombocytopenia
(<10,000/mm3) and active bleeding

31. Dengue fever management
 Continue monitoring after defervescence
 If any doubt, provide i.v fluids, guided by
serial HCt, BP and urine output

32. Dengue fever management
Unproven therapies
 Unknown if the use of steroids, intravenous
immune globulin, or platelet transfusions to
shorten the duration or decrease the severity
of thrombocytopenia is effective

33. Dengue fever management
Immunomodulatory therapy
 Corticosteroids have no role
 They do not alter mortality, bleeding severity,
duration of shock, need for fluid replacement,
or complications

34. Dengue fever management
When to plan discharge
 Clinical criteria
 Visible improvement in clinical picture
 No fever for 24 hours without anti-fever therapy
 Return of appetite with normal oral intake
 Normal urine output
 3 days after recovery from shock
 No respiratory distress from pleural effusions/ascites
 Lab criteria
 Stable hematocrit
 Platelets ≥ 50,000/mm3

35. Dengue fever management
 Master Rahul improved and was discharged
on day 7

36. Dengue fever management
 Prevention is better than cure….

37. Dengue fever management
Dengue Vaccine?
 No licensed vaccine at present
 Effective vaccine must be tetravalent
 Field testing of an attenuated tetravalent
vaccine currently underway
 Effective, safe and affordable vaccine will not
be available in the immediate future

38. Dengue fever management
Mosquito Barriers
 Only needed until fever subsides, to prevent
Aedes aegypti mosquitoes from biting
patients and acquiring virus
 Keep patient in screened sickroom or under a
mosquito net

39. Dengue fever management
Closing balance…
 Dengue virus infection has no ‘specific’
therapy
 But so much can be done to the patient

40. Dengue fever management
Message…
 Mortality reduction is five-fold
 Case fatality rate of dengue hemorrhagic
fever in most countries is 5 %
 This can be reduced 5-fold ie to < 1 % with
proper treatment

41. Dengue fever management
Apollo Experience
 Retrospective collection of 21 cases
 Year of study: 2005 – 2006
 Positive dengue by serology
 Data subject to collection bias

42. Dengue fever management
Demography
 21 hospitalized patients
 Male: Female :: 12: 9
 Age range: 5 months to 65 years

43. Dengue fever management
Age (in years)
0
1
2
3
4
5
6
7
8
0 - 5
years
6 - 20
years
20 -
50
years
> 50
years
3-D Column 1

44. Dengue fever management
Clinical features (n=21)
 Fever – 20
 Vomiting – 8
 Seizures – 2
 Myalgias – 8
 Sore throat – 1
 Breathlessness – 2
 Hemetemesis – 1
 Melena – 1
 Epistaxis – 1

45. Dengue fever management
Lab tests
 Platelets: Normal – 4; Low – 17
 Hematocrit rise in 11
 Leukopenia in 15
 Azotemia in 5; 1 needed peritoneal dialysis
 USG abdomen: hepatomegaly – 3;
splenomegaaly – 6
 Pleural effusion – 5
 Ascitis – 1
 CT scan – 2 - Normal

46. Dengue fever management
 Blood transfusion – 3
 Platelet transfusion – 3
 All were on antibacterial therapy –
 ? justification

47. Dengue fever management
 Duration of hospitalization: 3 – 25 days
 Oldest person – 65 years, stayed for 25 days
 Usual duration of stay 7 – 10 days

48. Dengue fever management
Morbidity
 One needed peritoneal dialysis
 Four needed ventilatory assistance
 One 35-year-old man expired
 Others were asymptomatic at discharge

49. Dengue fever management
Dengue misconceptions
Dengue + bleeding = DHF
Need 4 WHO criteria, capillary permeability
DHF kills only by hemorrhage
Patient dies as a result of shock
Poor management turns dengue into DHF
Poorly managed dengue can be more severe, but DHF is a
distinct condition, which even well-treated patients may
develop
Positive tourniquet test = DHF
Tourniquet test is a nonspecific indicator of capillary
fragility

50. Dengue fever management
Dengue - more
misconceptions
DHF is a pediatric disease
All age groups are involved
DHF is a problem of low income families
All socioeconomic groups are affected
Tourists will certainly get DHF with a second
infection
Tourists are at low risk to acquire DHF

51. Dengue fever management