Dengue

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

Practice Essentials
Dengue is the most common arthropod-borne viral (arboviral) illness in humans. It is transmitted by
mosquitoes of the genus Aedes, which are widely distributed in subtropical and tropical areas of the world
(see the image below).

Drawing of Aedes aegypti mosquito. Picture

from the Centers for Disease Control and Prevention (CDC) Web site.

A small percentage of persons who have previously been infected by one dengue serotype develop
bleeding and endothelial leak upon infection with another dengue serotype. This syndrome is termed
dengue hemorrhagic fever.
Dengue fever is typically a self-limiting disease with a mortality rate of less than 1%. When treated, dengue
hemorrhagic fever has a mortality rate of 2-5%, but when left untreated, the mortality rate is as high as
50%.
See 7 Bug Bites You Need to Know This Summer, a Critical Images slideshow, for helpful images and
information on various bug bites.

Essential update: Dengue may be underrecognized in the United States

As suggested by a recently reported case of a woman aged 63 years who died from complications of
dengue acquired in New Mexico or Texas in 2012, the disease may not be adequately recognized in the
United States as a source of potentially fatal acute febrile illness. The patient had initially been diagnosed
with West Nile virus, but a postmortem bone marrow biopsy revealed the presence of dengue virus. [1, 2]
In addition, the patients records revealed that she met the clinical case definition for hemophagocytic
lymphohistiocytosis, a hyperinflammatory syndrome that is sometimes associated with dengue and that in
this instance was the cause of death.

Signs and symptoms

Many patients with dengue experience a prodrome of chills, erythematous mottling of the skin, and facial
flushing, which may last for 2-3 days. Children younger than 15 years usually have a nonspecific febrile
syndrome, which may be accompanied by a maculopapular rash.

Accompanying symptoms in patients with dengue may include any of the following:

Headache
Retro-orbital pain
Severe myalgias: Especially of the lower back, arms, and legs
Arthralgias: Usually of the knees and shoulders
Nausea and vomiting (diarrhea is rare)
Rash: A maculopapular or macular confluent rash over the face, thorax, and flexor surfaces, with
islands of skin sparing
Weakness
Altered taste sensation
Anorexia
Sore throat
Mild hemorrhagic manifestations (eg, petechiae, bleeding gums, epistaxis, menorrhagia,
hematuria)
Lymphadenopathy
Dengue hemorrhagic fever
The initial phase of dengue hemorrhagic fever is similar to that of dengue fever and other febrile viral
illnesses. Shortly after the fever breaks (or sometimes within 24 hours before), signs of plasma leakage
appear, along with the development of hemorrhagic symptoms such as bleeding from sites of trauma,
gastrointestinal bleeding, and hematuria. Patients may also present with abdominal pain, vomiting, febrile
seizures (in children), and a decreased level of consciousness.
If left untreated, dengue hemorrhagic fever most likely progresses to dengue shock syndrome. Common
symptoms in impending shock include abdominal pain, vomiting, and restlessness. Patients also may have
symptoms related to circulatory failure.
See Clinical Presentation for more detail.

Diagnosis
Laboratory criteria for the diagnosis of dengue include 1 or more of the following:

Isolation of the dengue virus from serum, plasma, leukocytes, or autopsy samples
Demonstration of a fourfold or greater change in reciprocal immunoglobulin G (IgG) or IgM
antibody titers to 1 or more dengue virus antigens in paired serum samples

Demonstration of dengue virus antigen in autopsy tissue via immunohistochemistry or

immunofluorescence or in serum samples via enzyme immunoassay (EIA)

Detection of viral genomic sequences in autopsy tissue, serum, or cerebral spinal fluid (CSF)
samples via polymerase chain reaction (PCR) assay
The following laboratory tests should also be performed in the workup of patients with possible dengue:

Complete blood count (CBC)

Metabolic panel
Serum protein and albumin levels
Liver panel
Disseminated intravascular coagulation (DIC) panel
Characteristic findings in dengue fever are as follows:

Thrombocytopenia (platelet count < 100 x 109/L)

Leukopenia
Mild to moderate elevation of aspartate aminotransferase and alanine aminotransferase values
In patients with dengue hemorrhagic fever, the following may be present:

Increased hematocrit level secondary to plasma extravasation and/or third-space fluid loss
Hypoproteinemia
Prolonged prothrombin time
Prolonged activated partial thromboplastin time
Decreased fibrinogen
Increased amount of fibrin split products

Guaiac testing for occult blood in the stool should be performed on all patients in whom dengue virus
infection is suspected. Urinalysis identifies hematuria.
Imaging studies

Chest radiography
Head computed tomography (CT) scanning without contrast: To detect intracranial bleeding or
cerebral edema from dengue hemorrhagic fever

Ultrasonography: To detect fluid in the chest and abdominal cavities, pericardial effusion, and a
thickened gallbladder wall, in dengue hemorrhagic fever
See Workup for more detail.

Management
Oral rehydration therapy is recommended for patients with moderate dehydration caused by high fever and
vomiting.
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
Patients with internal or gastrointestinal bleeding may require transfusion, and patients with coagulopathy
may require fresh frozen plasma.
See Treatment and Medication for more detail.