Indian National Guidelines for clinical management of dengue fever provide guidance on diagnosing and treating the disease based on severity. Dengue can range from mild to severe. Mild cases involve fever without complications and can be managed at home. Moderate cases involve warning signs or high-risk patients who require close monitoring, possibly in a hospital. Severe dengue involves shock, organ involvement, or bleeding and requires intensive care. Diagnosis involves virus and antibody testing. Treatment is symptomatic and includes oral rehydration for mild cases but intravenous fluids and monitoring for moderate and severe cases.

1. Indian National Guidelines
Management of Dengue Fever
DR VAIBHAV GODE.
MD PEDIATRICS
ASSISTANT LECTUERER , SMBT MEDICAL COLLEGE
Indian national guidelines for clinical management of dengue fever by
Ashutosh Biswas, Ghanshyam Pangtey, Veena Devgan, Paras Singla,Pavana
Murthy, AC Dhariwal, PK Sen, Kalpana Baruah

2. EPIDEMIOLOGY
 Dengue is the most rapidly spreading
mosquito-borne viral disease in the world
 Increase in incidence by over 30-fold in
the last 50 years
 Currently endemic in all continents except
Europe

3. ETIOLOGY THE VIRUS
 DEN- family flaviviridae
genus flavivirus
 Has four distinct serotypes (DEN1 – 4)
 DEN-2 and DEN-3 cause severe disease

4. Dengue like viruses
VIRUS GEOGRAPHI
C GENUS
VECTOR DISTRIBUTIO
N
Togavirus Chikungunya Aedes aegypti Africa, India,
Southeast Asia, Latin
America,
United StatesAedes africanus
Aedes albopictus
Togavirus East O'nyong-nyong Anopheles funestus Africa
Flavivirus West Nile fever Culex molestus Europe,Africa,
Middle East, India
Culex univittatus

5.  Dengue viruses are transmitted by mosquitoes
of the Aedes aegypti, a daytime biting
mosquito, is the principal vector.
 Transmission occurs from viremic humans by
bite of the vector mosquito where virus
multiplies during an extrinsic incubation
period and then by bite is passed on to a
susceptible human in what is called the urban
transmission cycle.

6. Clinically the severity of dengue infection
is divided into three categories
Mild
Moderate
Severe

7. Mild Dengue Infection
 Characterized by undifferentiated DF, fever
without complications like bleeding,
hypotension,organ involvement or any
evidence of capillary leakage.
 These patients usually do not have warning
signs & symptoms; hence, can be managed at
home with proper counseling.

8. Moderate Dengue Infection
 Dengue infection with warning signs and
symptoms,DHF-I and II
 Dengue infection with high-risk and
comorbid conditions.

9. Moderate dengue with warning
signs and symptoms
 Indicators of severity as follows:
 Recurrent vomitinge
 Abdominal pain/Tenderness
 General weakness/leathargy/restlessness
 Minor bleeding
 Pleural effusion/Ascites
 Hepatomegaly
 Increased heamatocrit (Hct)
This patients require close monitoring.

10. DHF Grade I and Grade II with or
without minor bleeding
 These patients are DHF without hypotension or
shock.
 Sometimes, these patients with minor bleeding
may progress to severe plasma leakage and
could lead to organ involvement, massive
bleeding and shock.

11. Moderate dengue with high-risk
and comorbid conditions
The following factors are found to be associated
with high chances of progressing to severe
dengue infection:
1. Infants 4. Old age
2. Diabetes 5. Hypertension
3. Pregnancy 6. Coronary artery disease
7. Hemoglobinopathies
8. Immunocompromised patient
6 Patient on steroids, anticoagulants or
immunosuppressants.

12.  The moderate dengue patients should be
closely monitored or possibly
hospitalized for further management as these
groups of patients can develop severe dengue
manifestation due to abnormalities in metabolic
conditions, severe plasma leakage and increases
the mortality.

13. Severe Dengue Infection
 Recognized by the presence of shock, capillary
leakage, significant bleeding, severe organ
involvement and severe metabolic
abnormalities.
 This patients require intensive care
management.
 Investigation should be done to look for
abnormalities in coagulation profile, CBC and
organ function test.

14. Severe Dengue Infection
 Severe shock patients should be managed with
fluids very carefully to prevent organ damage
and pulmonary edema, which is associated
with high mortality.
 Management of organ failure like liver,
respiratory, cardiac and renal should be
targeted as early as possible to prevent
progression of the disease severity.
 These patients should be transferred to tertiary
level hospitals when indicated, without delay

15. Expanded Dengue Syndrome
 Clinical manifestations are as follows:
System Unusual or atypical manifestations
CNS involvement Encephalopathy, encephalitis, febrile
seizures, intracranial bleed
GIT involvement Acute hepatitis/fulminant hepatic
failure, cholecystitis, cholangitis, acute
pancreatitis
Renal involvement Acute renal failure, hemolytic uremic
syndrome, acute tubular necrosis

16. Expanded Dengue Syndrome
System Unusual or atypical manifestations
Cardiac involvement Cardiac arrhythmia, cardiomyopathy,
myocarditis, pericardial effusion
Respiratory Pulmonary edema, ARDS, pulmonary
hemorrhage, pleural effusion
Eye Conjunctival bleed, macular
hemorrhage,
visual impairment, optic neuritis

17. Laboratory Dignosis
 DF mimics other prevalent diseases such as
chikungunya, malaria, viral infection, urinary tract
infection, typhoid, leptospirosis,etc.
 Exclusion of other conditions based on clinical
features & laboratory investigations is important.
 Govt. of India recommends use of
1. ELISA-based antigen detection test (NS1) for
diagnosing the cases from 1st day onwards and
2. Antibody detection test immunoglobulin M
(IgM) capture ELISA (MAC-ELISA) for
diagnosing cases after 5th day of onset of disease.

18. Laboratory Dignosis
 A number of rapid diagnostic test (RDT) kits for
NS1 Ag and anti-dengue IgM/IgG antibodies are
commercially available at present, which produces
the results within 15-25 minutes.
 However, the accuracy of most of these tests is not
known.
 Hence ,currently, use of RDT is not recommended
under the program.

19. Clinical management
 Approach to clinical management of DF may vary
from mild,moderate and aggressive depending on
severity of illness. Fg 1
 Patients who have simple fever without any danger
signs or complications may be managed with
simple approach.
 Those who have danger signs should be managed
with close monitoring for progression of DHF/DSS
or severe bleeding.

20.  The patients presenting with Grade III and IV of
DHF, significant bleeding or involvement of
various organs will require aggressive management
to reduce morbidity and mortality.
 Patient may develop more complications during
later stage of fever (defervescence) or afebrile
phase, where clinician should be careful to look for
danger signs or severity of disease.

21. Dengue Viral Infection
Symptomatic Asymptomatic
Mild Severe dengueModerate dengue
DF with high-risk and
comorbid conditions
DF with warning signs & sympt
A.Undiffent. DF
B. Fever without
bleeding,hypoten
sion & organ
involvement
c.Without
capillary leakage
•Infants
•Old age
•Diabetes
•Hypertension
•Pregnancy
•CAD
•Hemoglobinopathy
•Immunocompromi
sed patient
•Patient on steroids,
anticoagulants or
immunosupressant
A. DF with warning
signs & symptoms
Recurrent vomiting
Abdominal pain
tenderness
General weakness/
letharginess/restle
Mild pleural
effusion/ascites
Hepatomegaly
Increased Hct>20%
B. DHF I & II with
minor bleeds
A. DF/DHF with
significant
hemorrhage
B. DHF with shock
(DHF III & IV- DSS)
c. Severe organ
involvement
(Expanded dengue
syndrome)
D. Severe
metabolic disorder
Home management Close monitoring* & hospitalization Tertiary level care
*Close monitoring: Hct, Plt, Hb, fluid intake/output, HR, RR, BP, Consciousness.

22. Management of dengue fever
 Management of DF is symptomatic and supportive.
 Antipyretics. i.e. paracetamol
 Aspirin/NSAID should be avoided since it may
cause gastritis, vomiting, acidosis, platelet
dysfunction and severe bleeding complication.
 Oral fluid and electrolyte therapy is recommended
for patients with excessive sweating, vomiting or
hypotension.

23.  Patients should be monitored for 24-48 hours in
DHF endemic areas until
I. They become afebrile without the use of
antipyretics and
II. Hematocrit determinations are stable.
III. Platelet count is >50,000/mm3 or improving.

24. Management of DHF (Febrile
Phase)
 Management of febrile phase is similar to that of
DF.
 Paracetamol is recommended to keep the
temperature below 39oC.
 Copious amounts of fluids should be given
orally, to the extent the patient tolerates, oral
rehydration solution (ORS), fruit juices are
preferable to plain water.
 IV fluids should be administered if the patient
is vomiting persistently or refusing to feed.

25.  Close monitoring should be done to look for
signs of shock.
 The critical period is during the transition from
the febrile to the afebrile stage and usually occurs
after the third day of illness.
 Serial hematocrit determinations are essential
guide for treatment, since they reflect the degree
of plasma leakage and need for IV administration
of fluids.
 Hematocrit should be done daily from the third
day until the temperature has remained normal
for 1-2 days.

26. Management of DHF Grade I and II
 Any person who has DF with thrombocytopenia &
hemoconcentration and presents with abdominal
pain, black tarry stools, epistaxis, bleeding from the
gums, etc. needs to be hospitalized.
 All these patients should be observed for signs of
shock. The critical period for development of shock
is during transition from febrile to afebrile phase of
illness,which usually occurs after third day of
illness.

27.  A rise of hemoconcentration indicates need for IV
fluid therapy. If patient develops fall in blood
pressure (BP), decrease in urine output or other
features of shock despite treatment, management
for Grade III/IV DHF/DSS should be instituted.
 Oral rehydration should be given along with
antipyretics like paracetamol, sponging, etc. as
described above.
 The algorithm for fluid replacement therapy in
case of DHF Grade I and II is given in Figure 2.

29. Management of Shock (DHF Grade
III/IV)
 Immediately Hospitalization,
 Vital signs & platelet count should checked.
 IV fluid therapy should be started.
 The patient requires regular and continuous
monitoring.

30. Management of Shock (DHF Grade
III/IV)
 If the patient has already received about 1,000 mL
of IV fluids, it should be changed to colloidal
solution preferably Dextran 40/haemaccel.
 If he hematocrit is falling, fresh whole blood
transfusion 10-20 mL/kg/dose should be given.
 However, in case of persistent shock when, after
initial fluid replacement and resuscitation with
plasma or plasma expanders, the hematocrit
continues to decline, internal bleeding should be
suspected.

31.  It may be difficult to recognize and estimate the
degree of internal blood loss in the presence of
hemoconcentration. Hence, whole blood in small
volumes of 10 mL/kg/hour for all patients in shock
as a routine precaution is recommended.
 Oxygen should be given to all patients in shock.
 Treatment algorithms for patients with DHF
Grades III and IV are given in Figures 3 and 4.

34. Calculation of Fluid
 The required amount of fluid should be calculated
on the basis of body weight and charted on 1-3
hourly basis or even more frequently in the case of
shock.
 For obese and overweight patients, fluid should be
calculated on the basis of ideal body weight.
 The regimen of the flow of fluid and the time of
infusion are dependent on the severity of DF.
 It is calculated for dehydration of about 5% deficit
(plus maintenance).
 The maintenance fluid should be calculated using
the Holiday-Segar formula.

35.  For a child weighing 40 kg, the maintenance is:
1,500 + (20× 20) = 1,900 mL. Amount of fluid to
be given in 24 hours is calculated by adding
maintenance + 5% dehydration,which is equivalent
to 50 mL/kg.
 This should be given in 24 hours to maintain just
adequate intravascular volume and circulation.
 Therefore, for a child weighing 40 kg the fluid
required will be 1,900 + (40 × 50) = 3,900 mL in
24 hours.
 For IV fluid therapy of patients with DHF, four
regimens of flow of fluid are suggested i.e.
3 mL/kg/hour; 6 mL/kg/hour; 10 mL/kg/hour &
20 mL/kg/hour.

36. Management of Severe Bleeding
 In case of severe bleeding, patient should be
hospitalised and investigated to look for the cause
and site of bleeding and immediate attempt should
be made to stop the bleeding.
 Internal bleeding like gastrointestinal (GI)
bleeding may be sometime severe and difficult to
locate.
 Patients may also have severe epistaxis and
hemoptysis and may present with profound shock.
 Urgent blood transfusion is life-saving in this
condition. However, if blood is not available shock
may be managed with proper IV fluid or plasma
expander (i.e. haemaccel).

37.  If the patient has thrombocytopenia with active
bleeding, it may be corrected with platelet
transfusion.
 In case of massive hemorrhage, blood should be
tested to rule out coagulopathy by testing for
prothrombin time (PT) and activated partial
thromboplastin time (aPTT).
 Patients of severe bleeding may have liver
dysfunction and in this case, liver function tests
(LFTs) should also be performed. Rarely,
intracranial bleed may also occur in some patients,
who have severe thrombocytopenia and abnormal
coagulation profile.

38. Management of Dengue Fever with
comorbid illness
 Different comorbid illness like hypertension,
diabetes, thyroid, liver, heart and renal diseases
may contribute in the development of severe
manifestations in DF.

39. Dengue Hepatitis
 Dengue infection itself may lead impairment of
LFT . Some of DF patients ,SGOT /SGPT level may
be very high and PT may be prolonged.
 Hepatic involvement is can be associated with
preexisting conditions like viral hepatitis, cirrhosis
of liver and hepatomegaly due to some other cause.
 Patient may also develop hepatic encephalopathy
due to severe liver failure.

40.  Hepatic impairment sometimes associates with DF
in pregnancy.
 Low albumin due to chronic liver disease can lead
to severe DHF and bleeding. GI bleeding is
common in this condition and patient may go into
severe DSS.
 These patients should be managed carefully with
hepatic failure regimen with appropriate fluid and
blood transfusion. If PT is prolonged, IV vitamin K1
may be initiated in such conditions.

41. Dengue Myocarditis
 Dengue infection may rarely cause acute
myocarditis,which may also contribute to the
development of DSS.
 Cardiac complications may be seen in presence of
CAD, hypertension, diabetes and valvular heart
disease.
 Management of shock with IV fluids is difficult due
to myocardial dysfunction.
 Patient may develop pulmonary edema due to
improper fluid management.

42.  CAD patients on aspirin and other antiplatelet
agents, which may also contribute to severe
bleeding unless these are stopped during dengue
infection.
 Cardiac ischemia or electrolyte disturbances may
be reassessed.
 Patient may develop congestive or biventricular
failure .

43. DF in Diabetes
Sometimes severe complications may present
with in DF when target organs are involved like
 Diabetic retinopathy,
 Neuropathy,
 Nephropathy,
 Vasculopathy,
 Cardiomyopathy and
 Hypertension.
 Due to dengue infection, the blood sugar may
become uncontrolled, which may sometimes
require insulin therapy for better management.

44. Renal Involvement in DF
 Acute tubular necrosis (ATN) may develop during
DSS and may cause acute kidney injury (AKI) if
fluid therapy is not initiated in time.
 Renal function may be reversible, if shock is
correacted within short span of time;but if the
shock persists for long time patient may develop
renal complications.
 Urine output monitoring in dengue infection is very
important to assess renal involvement.
 Microscopic and macroscopic hematuria should be
examined in DHF patients

45.  Blood urea, creatinine, electrolytes, arterial blood
gas (ABG) should be monitored in patients with
severe dengue/DHF.
 Fluid intake should be closely monitored in case of
AKI to avoid fluid overload and pulmonary edema.
 Dengue patient may develop severe DHF in
presence of diabetic nephropathy, hypertensive
nephropathy, connective tissue disorders like
systemic lupus erythematosus (SLE) and other pre-
existing chronic diseases.

46. CNS Involvement in DF
 Altered sensorium may develop in dengue
patients due to various conditions like shock,
(DSS), electrolyte imbalance (due to persistent
vomiting), fluid overload (delusional
hyponatremia or other electrolyte),
hypoglycemia and also due to involvement of
central nervous system (CNS) by dengue virus.
 Acute encephalopathy or encephalitis may be
seen in some patients with severe dengue.

47.  Sometimes, it may be difficult to exclude
clinically cerebral malaria and enteric
encephalopathy, which are also seen during the
same period (epidemic).
 Dengue serology (IgM) in cerebrospinal fluid
may help to confirm dengue encephalopathy or
encephalitis.

48. Management of DF with coinfections
 It is sometimes difficult to manage DF with
coinfections like malaria, chikungunya,
tuberculosis (TB), human immunodeficiency
virus (HIV), enteric fever and Leptospirosis
because clinical presentations are mostly
severe in the presence of these coinfections.

49. Chikungunya
 In some geographical areas, both infections are
prevalent at the same time.
 Acute complications are sometimes severe in
DF in presence of chikungunya.
 In case of predominant joint involvement in a
DF patient, chikungunya should be
investigated and proper management should be
carried out accordingly.

50. Malaria
 Malaria is a common coinfection in dengue as
it is prevalent across our country and
transmission also coincides during the same
period/season.
 Malaria should be excluded in the beginning as
it has its specific management.
 Antimalarial treatment should be started as
soon as possible to prevent complication and
better outcome during coinfection.

51. TB
 Patients may develop breathlessness and
massive hemoptysis in pulmonary TB.
 These patients may develop pleural effusion
and acute respiratory distress syndrome
(ARDS).
 If patient has DF in presence of TB and is on
anti-TB treatment (ATT), then he/she should
be closely monitored for further development
of respiratory/pulmonary complications to
prevent morbidity and mortality.

52. Enteric fever
 Water-borne diseases like typhoid fever and
gastroenteritis are also common during the
monsoons when dengue infection is also
reported in large numbers.
 In the initial phase, DF patient may be
more complicated with typhoid if antibiotic
treatment is started late.
 In high suspected cases, blood culture for
typhoid fever should be sent to confirm
diagnosis as Widal test may not be positive
before 2 weeks of fever

53. Management of Dengue in infants
 Dengue Without Warning Signs
 Oral rehydration with oral rehydration solution
(ORS), fruit juice and other fluids containing
electrolytes and sugar should be encouraged
together with breastfeeding or formula feeding.
 Parents or caregivers should be instructed about
fever control with antipyretics and tepid sponging.
 They should be advised to bring the infant back to
the nearest hospital immediately if the infant has
any of the warning signs.

54. Dengue with Warning Signs
 When the infant has dengue with warning
signs, IV fluid therapy is indicated.
 In the early stage, judicious volume
replacement by IV fluid therapy may modify
the course and severity of the illness.
 Initially, isotonic crystalloid solutions such as
Ringer’s lactate (RL), Ringer’s acetate (RA) or
0.9% saline solution should be used.
 The capillary leak resolves spontaneously
after24-48 hours in most of the patients.

55. Severe Dengue: Treatment of shock
 Volume replacement in infants with dengue shock
is very challenging and it should be done promptly
during the period of effervescence.
 Each and every case should be critically analyzed
separately and following points in general should
be kept in mind during management.

56. Management of Dengue Infection in
outbreak situation
 During outbreak situation, dengue patient turnover
may increase exceptionally.
 All hospitals in endemic areas should have a plan
dealing with emergency hospitalization to make the
most effective use of hospital and treatment
facilities in case of outbreak occurs.

57. Criteria for admission of a patient
 If a DF patient presents with significant bleeding
from any site, signs of hypotension, persistent
high-grade fever, rapid fall of platelet count,
sudden drop in temperature, he/she should be
admitted in hospital.
 Patients who have evidence of organ involvement
should also be admitted for proper monitoring and
management.
 Dengue patients with warning signs and symptoms
should be admitted and closely monitored

58. Criteria for discharge of patients
Discharge criteria as follows:
 No fever for at least 24 hours,
 Normal BP,
 Adequate urine output,
 No respiratory distress,
 Persistent platelet count >50,000/mm3

59. Indications of platelet transfusion
 In general, there is no need to give prophylactic
platelets even at <20,000/mm3.
 Prophylactic platelet transfusion may be given
at level of <10,000/mm3 in absence of
bleeding manifestations.
 Platelet transfusion may also be given in
prolonged shock with coagulopathy and
abnormal coagulogram.
 In case of systemic massive bleeding, platelet
transfusion may be needed in addition to red
cell transfusion.

60.  Standard dose for adults is 5-6 units of random
donor platelets or 1 unit of apheresis platelets
or 1 unit of BCPP equivalent to 3 × 1011
platelets.
 For a neonates/infants, the dose of platelets
should be 10-15 mL/kg of body weight.
 Useof fresh frozeplasma/cryoprecipitate
in coagulopathy with bleeding should be as per
patient’s condition.

61. Conclusion
 The basic management of dengue infection is
targeted symptomatically.
 In the early stage, if signs and symptoms are
identified to grade the severity, it could help the
clinicians for appropriate intervention and better
outcome for reducing the morbidity and mortality.