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id.dengue.v1PRODUCTION
id.dengue.v1

Dengue (DENV-1/2/3/4) — without warning signs + with warning signs (critical phase) + severe dengue (DSS / bleeding / organ failure) + pregnancy + secondary heterologous infection + returning traveler differential + fluid overload recovery + vaccine decision (Dengvaxia seropositive-only / Qdenga any serostatus where approved)

infectious_diseaseacutesubacuteadultpediatricpregnancygeriatric
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Encounter flow

12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Dengue spectrum: dengue without warning signs (febrile-phase outpatient) + dengue with warning signs (critical-phase admission) + severe dengue (shock DSS / severe bleeding / severe organ failure — ICU) + pregnancy (admit regardless of warning-sign status) + secondary heterologous infection (ADE; lifetime serology counseling) + returning-traveler differential (co-test malaria / typhoid / lepto / rickettsial / chikungunya / zika) + fluid overload in recovery phase (third-space mobilization → cautious diuresis) + dengue vaccine decision (Dengvaxia seropositive-only ≥ 9 yo per CDC ACIP 2021; Qdenga any serostatus 4-60 yo where approved per EMA 2022). Three-phase pathology: febrile (days 1-3) → critical (days 4-6) → recovery (days 7-10) (WHO 2009 + 2024)

Inputs
2
Actions
2
Advance rule
Set
Advance when

Dengue phenotype framed (without / with warning signs / severe / pregnancy / secondary / returning traveler / vaccine / recovery overload) and disease-phase day count anchored

Patient inputs (23)

Pediatric weight-based dose for paracetamol + IV crystalloid; infants < 12 mo severe-prone (low admission threshold); Dengvaxia ≥ 9 yo; Qdenga 4-60 yo (CDC ACIP 2021 PMID 34978547; Biswal NEJM 2019 PMID 31693803)

Travel from dengue-endemic region (Southeast Asia, Caribbean, Latin America, sub-Saharan Africa) within 14 d (max incubation ~ 14 d) raises pre-test probability sharply (CDC Yellow Book 2024)

Prior dengue infection OR seropositive baseline serology raises secondary-heterologous-infection severity risk via ADE (Halstead Lancet 2007 PMID 17993365); informs vaccine decision (Dengvaxia seropositive-only)

Pregnant patient → admit regardless of warning-sign status; vertical transmission peripartum + PPH + neonatal dengue surveillance (ACOG; Paixao Lancet ID 2016 PMID 26949028)

Fever ≥ 39 °C in febrile phase; defervescence around day 3-5 marks transition to critical phase (WHO 2009; Simmons NEJM 2012)

Day count drives phase-specific management: febrile (days 1-3) symptomatic + warning-sign teaching; critical (days 4-6) IV crystalloid + serial Hct; recovery (days 7-10) cautious diuresis if pulmonary edema (WHO 2009 + 2024)

Serial Hct + platelets q4-6h in critical phase — Hct rise concurrent with rapid platelet fall = plasma leakage warning sign; Hct ≥ 20% increase from baseline + plt < 100 = severe critical phase (WHO 2009 + 2024)

NS1 antigen sensitivity ~ 60-90% serotype-dependent, specificity ~ 95-99%, LR+ ~ 20-50 in first 5 d of illness; high yield early when IgM still negative (WHO 2024; CDC Yellow Book 2024)

IgM ELISA from day 4+ sensitivity ~ 90% by day 5-10, specificity ~ 90%; cross-reactivity with other flaviviruses (zika, yellow fever, JE) so interpret with epidemiology (WHO 2024; CDC Yellow Book 2024)

AST / ALT ≥ 1000 = severe organ dysfunction (hepatitis criterion for severe dengue); also drives paracetamol max-dose adjustment (60 mg/kg/d in hepatitic patient) (WHO 2009 + 2024)

PT / PTT / fibrinogen baseline for severe bleeding management — cryoprecipitate / FFP if coagulopathy / low fibrinogen; coags trend in severe dengue (WHO 2009 + 2024)

Baseline + serial; AKI (Cr × 1.5-3 baseline) = severe organ dysfunction criterion; drives dose-adjust for renally-cleared meds (WHO 2009 + 2024)

Narrow pulse pressure ≤ 20 mmHg OR overt hypotension = shock (DSS) — life-threatening; SBP / DBP + MAP + capillary refill — titrate fluid by Hct + UOP + clinical, NOT MAP alone (WHO 2009 + 2024; Wills NEJM 2005 PMID 16135832)

Cap refill > 2 s + cold extremities + tachycardia = compensated shock; titrate IV crystalloid by Hct + UOP + clinical (WHO 2009 + 2024)

UOP < 0.5 mL/kg/h in adult OR < 1 mL/kg/h in pediatric = decreased perfusion; titrate IV crystalloid (WHO 2009 + 2024)

Lactate baseline for shock severity assessment + clearance trend during resuscitation (WHO 2009 + 2024; SSC 2026)

Diabetes, chronic anticoagulation, sickle cell, immunocompromise all raise severe-dengue risk + lower admission threshold (WHO 2009 + 2024)

RT-PCR sensitivity ~ 80-100% in first 5 d, specificity ~ 99%, LR+ > 100; serotype-specific (research / outbreak / atypical setting) (WHO 2024)

Blood cultures + co-test for typhoid (Salmonella), leptospirosis (lepto IgM), rickettsial (eschar / serology) in returning traveler with febrile illness; bacterial co-infection / sepsis bridge differential (CDC Yellow Book 2024)

Returning traveler with fever from endemic region → co-test malaria (thick + thin smear + RDT HRP2 / pLDH); cross-route to id.malaria.v1 (CDC Yellow Book 2024)

Bedside ultrasound — pleural effusion + ascites + gallbladder wall thickening = plasma leakage signs in critical phase; supports warning-sign + severe-dengue stratification (WHO 2009 + 2024)

CXR for fluid accumulation (pleural effusion + pulmonary edema) — supports severe-dengue criterion (fluid accumulation with respiratory distress) + recovery-phase fluid-overload surveillance (WHO 2009 + 2024)

Pre-vaccination serology MANDATORY for Dengvaxia (CYD-TDV) — seropositive (rapid IgG OR ELISA) ≥ 9 yo only; seronegative is CONTRAINDICATION (CDC ACIP 2021 PMID 34978547)

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Severity triggers (10)

10 need judgement
  • informationallife_threateningsevere_dengue_shock_dss
    Severe dengue with shock (DSS — life-threatening) — narrow pulse pressure ≤ 20 mmHg, overt hypotension, cap refill > 2 s, cold extremities, tachycardia, decreased UOP; ICU + IV crystalloid bolus 10-20 mL/kg over 1 h (compensated) or 15-30 min (hypotensive); titrate by Hct + UOP + clinical (NOT MAP alone — over-titration to high MAP can mask under-resuscitation); colloid (dextran 40) 10 mL/kg for fluid-refractory; vasopressor (norepinephrine) for vasopressor-dependent per SSC 2026; avoid blanket 30 mL/kg sepsis bolus per dengue-specific cautious-fluid caveat (WHO 2009 + 2024; Wills NEJM 2005 PMID 16135832; SSC 2026)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningsevere_bleeding_dengue
    Severe dengue with severe bleeding (life-threatening) — GI / GU / intracranial / mucosal hemorrhage with hemodynamic instability; packed RBC transfusion for active bleeding (NOT prophylactic regardless of platelet count); cryoprecipitate / FFP if coagulopathy / low fibrinogen; tranexamic acid considered per ID consult for severe bleeding (data emerging, not yet standard); **NO prophylactic platelet transfusion regardless of count per WHO 2009 + Lye Lancet 2017 PMID 28283286** (RCT showed no reduction in bleeding); ICU + correct shock (WHO 2009 + 2024; Lye Lancet 2017 PMID 28283286)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningsevere_organ_failure_dengue
    Severe dengue with severe organ dysfunction (life-threatening) — hepatitis (AST/ALT ≥ 1000; reduce paracetamol max-dose to 60 mg/kg/d pediatric / 2 g/d adult; avoid additional hepatotoxic drugs), encephalitis (altered mental status, seizures, focal deficits — HSV encephalitis is major treatable mimic; empiric IV acyclovir 10 mg/kg q8h pending HSV PCR per Tunkel IDSA encephalitis 2008), myocarditis (cardiac dysfunction, arrhythmia, troponin elevation — echo + ECG + ICU + avoid fluid overload), AKI (Cr × 1.5-3 baseline; CRRT if RRT-requiring); ICU + supportive + organ-specific (WHO 2009 + 2024; Tunkel IDSA encephalitis 2008)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverewarning_signs_in_critical_phase
    Dengue with warning signs in critical phase (days 4-6, defervescence + plasma leakage window) — abdominal pain or tenderness, persistent vomiting, clinical fluid accumulation (ascites / pleural effusion), mucosal bleed, lethargy / restlessness, hepatomegaly > 2 cm, Hct rise concurrent with rapid platelet fall; admit for IV crystalloid maintenance (LR or NS 5-7 → 3-5 → 2-3 mL/kg/h) + serial Hct + platelets q4-6h; transition to severe dengue within hours possible (WHO 2009 + 2024; PAHO 2022; AAP Red Book 2024)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveredengue_in_pregnancy
    Dengue in pregnancy (any trimester) — severe; admit for surveillance regardless of warning-sign status; vertical transmission risk peripartum (neonatal dengue surveillance: vesicle / cord blood PCR + serial CBC + LFT for neonate) + PPH risk + maternal-fetal medicine consult; teratogenicity controversial in dengue (less established than rubella, zika); maternal mortality elevated especially with severe disease; MMR equivalent contraindication NOT applicable (Dengvaxia + Qdenga are live attenuated and CONTRAINDICATED in pregnancy); postpartum vaccination planning where approved (ACOG; Paixao Lancet ID 2016 PMID 26949028; WHO 2024)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveredengue_with_secondary_infection
    Suspected secondary heterologous dengue infection (prior documented dengue OR seropositive baseline serology) — severe; antibody-dependent enhancement (ADE) raises severe-dengue risk ~ 7-10× primary infection (Halstead Lancet 2007 PMID 17993365); admit threshold lower; lifetime serology baseline documented + counseling on secondary-heterologous-infection ADE risk for future endemic-area travel; vaccine decision: Dengvaxia (CYD-TDV) appropriate for seropositive ≥ 9 yo + Qdenga (TAK-003) any serostatus 4-60 yo where approved (CDC ACIP 2021 PMID 34978547; EMA 2022)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereavoid_nsaids_aspirin_im
    AVOID aspirin / NSAIDs / IM injections / anticoagulants / corticosteroids in dengue critical phase — severe; bleeding risk (aspirin → Reye + bleeding; NSAIDs → bleeding + AKI; IM injections → hematoma in thrombocytopenia; anticoagulants → bleeding; corticosteroids no benefit, signal of harm); paracetamol ONLY for fever / pain (max 60 mg/kg/d pediatric or hepatitic; max 4 g/d adult, 2 g/d if hepatitis) per WHO 2009 + 2024 + AAP Red Book 2024 + FDA labels
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverefluid_overload_recovery_phase
    Fluid overload in dengue recovery phase (days 7-10) — severe; third-space mobilization → pulmonary edema if over-resuscitated in critical phase; clinical features: dyspnea + crackles + CXR pulmonary congestion + falling Hct from haemodilution as third-space fluid returns to intravascular; reduce IV fluids + cautious furosemide IF clinical pulmonary edema (NOT prophylactic); reassess for myocarditis / cardiac dysfunction (echo + ECG + troponin); ICU monitoring if severe (WHO 2009 + 2024)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatetravel_history_returning_traveler_with_febrile_illness
    Returning traveler with febrile illness from dengue-endemic region (Southeast Asia, Caribbean, Latin America, sub-Saharan Africa) within 14 d — moderate; broad ddx (dengue + malaria + chikungunya + zika + typhoid + leptospirosis + rickettsial + hepatitis A + acute HIV); co-test always (thick + thin smear + RDT for malaria + dengue NS1 + IgM + RT-PCR + blood cultures + lepto IgM + rickettsial serology); cross-route to id.malaria.v1; empiric ceftriaxone if bacterial co-infection / typhoid / sepsis cannot be excluded; doxycycline empiric if rickettsial / lepto suspected; airborne not needed (dengue is vector-borne, not contact) (CDC Yellow Book 2024; WHO 2024)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmilddengue_vaccine_decision_seropositive_or_serostatus_independent
    Dengue vaccine decision: Dengvaxia (CYD-TDV) for seropositive ≥ 9 yo only with MANDATORY pre-vaccination serology (rapid IgG OR ELISA); seronegative is CONTRAINDICATION per Sridhar NEJM 2018 PMID 29897841 (RR ~ 1.4-2× severe dengue + hospitalization in vaccinated seronegatives vs placebo); 3-dose schedule at 0/6/12 mo per CDC ACIP 2021 PMID 34978547. Qdenga (TAK-003) for any serostatus 4-60 yo where approved (EMA 2022; EU + UK + several Latin American countries); 2-dose schedule at 0/3 mo per Biswal NEJM 2019 PMID 31693803 + Tricou Lancet Glob Health 2024 PMID 38245116; NOT yet FDA-approved as of 2026-05-15 (mild)
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

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Recommended regimen

Dengue supportive care + paracetamol + IV crystalloid (LR / NS) titrated by Hct + UOP + clinical + colloid (dextran 40) for fluid-refractory shock + packed RBC for active bleeding + NO prophylactic platelet transfusion + empiric IV acyclovir for encephalitis differential + furosemide cautious in recovery phase + Dengvaxia (CYD-TDV) seropositive ≥ 9 yo + Qdenga (TAK-003) any serostatus 4-60 yo where approved
axis: dengue_supportive_fluid_and_vaccinestep paracetamol_only_avoid_nsaids_aspirin - Paracetamol ONLY for fever / pain — AVOID aspirin / NSAIDs / IM injections / anticoagulants (bleeding risk in critical phase)
Selected step "Paracetamol ONLY for fever / pain — AVOID aspirin / NSAIDs / IM injections / anticoagulants (bleeding risk in critical phase)" — ANY dengue phenotype (febrile / critical / recovery) — fever or pain control
  • acetaminophen
    first line
    analgesic_antipyretic
    Pediatric: 10-15 mg/kg/dose q4-6h PRN (max 60 mg/kg/d in dengue critical phase or hepatitic); adult: 500-1000 mg q6h PRN (max 4 g/d if no hepatitis; 2 g/d if hepatitis) • PO • q4-6h PRN
    triggers: fever, myalgia, arthralgia, headache
    Paracetamol ONLY in dengue — AVOID aspirin (Reye syndrome + bleeding), NSAIDs (bleeding + AKI), IM injections (hematoma in thrombocytopenia), anticoagulants (bleeding). Max dose reduced to 60 mg/kg/d pediatric / 2 g/d adult if hepatitic (AST/ALT ≥ 1000) per WHO 2009 + 2024 + AAP Red Book 2024
    rxcui 161

outpatient playbook — drug actions (4)

  1. 1. acetaminophen (paracetamol)
    Pediatric 10-15 mg/kg/dose q4-6h PRN (max 60 mg/kg/d if hepatitic); adult 500-1000 mg q6h PRN (max 4 g/d; 2 g/d if hepatitis) • PO • q4-6h PRN
    trigger: Fever or pain
    Paracetamol ONLY; AVOID aspirin / NSAIDs / IM injections / anticoagulants — bleeding risk per WHO 2009 + 2024
  2. 2. oral rehydration solution (ORS)
    WHO-formulation ORS — sip frequently throughout day; ad libitum • PO • continuous sip
    trigger: Dengue without warning signs tolerating PO
    WHO 2009 + 2024 — maintains hydration; reduces hospital admission for dehydration
  3. 3. Dengvaxia (CYD-TDV)
    0.5 mL SC × 3 doses • SC • dose 1 + dose 2 at 6 mo + dose 3 at 12 mo
    trigger: Seropositive ≥ 9 yo + endemic area or travel + no pregnancy + no severe immunocompromise; MANDATORY pre-vaccination serology
    CDC ACIP 2021 PMID 34978547 — seropositive-only; seronegative is CONTRAINDICATION per Sridhar NEJM 2018 PMID 29897841
  4. 4. Qdenga (TAK-003)
    0.5 mL SC × 2 doses • SC • dose 1 + dose 2 at 3 mo
    trigger: Age 4-60 yo + endemic area or travel + region where Qdenga is approved (EU + UK + several Latin American countries); pre-vaccination serology NOT required; no pregnancy + no severe immunocompromise
    EMA 2022 — indicated regardless of serostatus per Biswal NEJM 2019 PMID 31693803 + Tricou Lancet Glob Health 2024 PMID 38245116; NOT yet FDA-approved as of 2026-05-15

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Acute high fever ≥ 39 °C + retro-orbital pain + breakbone myalgia + arthralgia + facial flushing + transient maculopapular rash + headache — classical dengue febrile-phase presentation (WHO 2009 + 2024; Simmons NEJM 2012 PMID 22494122); Warning signs in critical phase (days 4-6, defervescence): abdominal pain or tenderness, persistent vomiting, clinical fluid accumulation (ascites / pleural effusion), mucosal bleed, lethargy / restlessness, hepatomegaly > 2 cm, Hct rise concurrent with rapid platelet fall (WHO 2009 + 2024); Severe dengue with shock (DSS) — narrow pulse pressure ≤ 20 mmHg, cap refill > 2 s, overt hypotension, cold extremities, tachycardia, decreased UOP — life-threatening (WHO 2009 + 2024; Wills NEJM 2005 PMID 16135832).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Dengue (DENV-1/2/3/4) — without warning signs + with warning signs (critical phase) + severe dengue (DSS / bleeding / organ failure) + pregnancy + secondary heterologous infection + returning traveler differential + fluid overload recovery + vaccine decision (Dengvaxia seropositive-only / Qdenga any serostatus where approved)** (id.dengue.v1).
Phenotype framing: Dengue vs malaria (cyclical fever + smear / RDT positive — cross-route id.malaria.v1; co-test always), chikungunya (prominent persistent arthralgia + small-joint involvement + chronic > 3 mo course — chikungunya PCR), zika (rash + conjunctivitis + milder fever + teratogenic CZS risk — zika PCR), yellow fever (dramatic hepatitis with jaundice + hemorrhagic phenotype in endemic Africa + S. America), typhoid (prolonged fever + relative bradycardia + rose spots + leukopenia — blood + stool culture), leptospirosis (water-exposure history + conjunctival suffusion + AKI — lepto IgM + PCR), rickettsial (eschar + tick / mite exposure — serology; doxycycline empiric), septicemia (bacterial source + procalcitonin > 0.5 + blood cultures — broad-spectrum empiric), measles (3 C's prodrome + Koplik + cephalocaudal maculopapular + outbreak), influenza (rapid antigen + circulating influenza season) (CDC Yellow Book 2024; WHO 2024)
Scope: Dengue spectrum: dengue without warning signs (febrile-phase outpatient) + dengue with warning signs (critical-phase admission) + severe dengue (shock DSS / severe bleeding / severe organ failure — ICU) + pregnancy (admit regardless of warning-sign status) + secondary heterologous infection (ADE; lifetime serology counseling) + returning-traveler differential (co-test malaria / typhoid / lepto / rickettsial / chikungunya / zika) + fluid overload in recovery phase (third-space mobilization → cautious diuresis) + dengue vaccine decision (Dengvaxia seropositive-only ≥ 9 yo per CDC ACIP 2021; Qdenga any serostatus 4-60 yo where approved per EMA 2022). Three-phase pathology: febrile (days 1-3) → critical (days 4-6) → recovery (days 7-10) (WHO 2009 + 2024)

No severity triggers fired against current inputs.

Plan

Regimen axis: **Dengue supportive care + paracetamol + IV crystalloid (LR / NS) titrated by Hct + UOP + clinical + colloid (dextran 40) for fluid-refractory shock + packed RBC for active bleeding + NO prophylactic platelet transfusion + empiric IV acyclovir for encephalitis differential + furosemide cautious in recovery phase + Dengvaxia (CYD-TDV) seropositive ≥ 9 yo + Qdenga (TAK-003) any serostatus 4-60 yo where approved** — step "Paracetamol ONLY for fever / pain — AVOID aspirin / NSAIDs / IM injections / anticoagulants (bleeding risk in critical phase)".
1. acetaminophen Pediatric: 10-15 mg/kg/dose q4-6h PRN (max 60 mg/kg/d in dengue critical phase or hepatitic); adult: 500-1000 mg q6h PRN (max 4 g/d if no hepatitis; 2 g/d if hepatitis) PO q4-6h PRN (analgesic_antipyretic, first line) — Paracetamol ONLY in dengue — AVOID aspirin (Reye syndrome + bleeding), NSAIDs (bleeding + AKI), IM injections (hematoma in thrombocytopenia), anticoagulants (bleeding). Max dose reduced to 60 mg/kg/d pediatric / 2 g/d adult if hepatitic (AST/ALT ≥ 1000) per WHO 2009 + 2024 + AAP Red Book 2024

Setting playbook (outpatient) — Manage dengue without warning signs in immunocompetent adult / child / adolescent on paracetamol + ORS + daily return for warning-sign + CBC review during days 3-7 (critical-phase transition window); return precautions; vaccine decision (Dengvaxia seropositive-only ≥ 9 yo per CDC ACIP 2021; Qdenga any serostatus 4-60 yo where approved per EMA 2022); travel-medicine counseling (vector avoidance + DEET repellent + permethrin-treated clothing + standing-water elimination); post-illness follow-up + lifetime serology baseline + counseling on secondary-heterologous-infection ADE risk for future endemic-area travel (WHO 2009 + 2024; CDC Yellow Book 2024; AAP Red Book 2024; Halstead Lancet 2007 PMID 17993365)
2. acetaminophen (paracetamol) Pediatric 10-15 mg/kg/dose q4-6h PRN (max 60 mg/kg/d if hepatitic); adult 500-1000 mg q6h PRN (max 4 g/d; 2 g/d if hepatitis) PO q4-6h PRN — Fever or pain (Paracetamol ONLY; AVOID aspirin / NSAIDs / IM injections / anticoagulants — bleeding risk per WHO 2009 + 2024)
3. oral rehydration solution (ORS) WHO-formulation ORS — sip frequently throughout day; ad libitum PO continuous sip — Dengue without warning signs tolerating PO (WHO 2009 + 2024 — maintains hydration; reduces hospital admission for dehydration)
4. Dengvaxia (CYD-TDV) 0.5 mL SC × 3 doses SC dose 1 + dose 2 at 6 mo + dose 3 at 12 mo — Seropositive ≥ 9 yo + endemic area or travel + no pregnancy + no severe immunocompromise; MANDATORY pre-vaccination serology (CDC ACIP 2021 PMID 34978547 — seropositive-only; seronegative is CONTRAINDICATION per Sridhar NEJM 2018 PMID 29897841)
5. Qdenga (TAK-003) 0.5 mL SC × 2 doses SC dose 1 + dose 2 at 3 mo — Age 4-60 yo + endemic area or travel + region where Qdenga is approved (EU + UK + several Latin American countries); pre-vaccination serology NOT required; no pregnancy + no severe immunocompromise (EMA 2022 — indicated regardless of serostatus per Biswal NEJM 2019 PMID 31693803 + Tricou Lancet Glob Health 2024 PMID 38245116; NOT yet FDA-approved as of 2026-05-15)

Non-pharmacologic actions:
- Daily return for warning-sign + CBC + tourniquet test review during days 3-7 (critical-phase transition window)
- Return precautions for new abdominal pain / persistent vomiting / clinical fluid accumulation / mucosal bleed / lethargy / restlessness / hepatomegaly / Hct rise + platelet fall
- Travel-medicine counseling: vector avoidance + DEET-containing repellent + permethrin-treated clothing + standing-water elimination + pre-trip vaccination decision for future endemic-area travel
- Lifetime serology baseline documented for future vaccine + risk-management decisions
- Counseling on secondary-heterologous-infection ADE risk for future endemic-area travel (Halstead Lancet 2007 PMID 17993365)
- Public health reporting per local regulations (dengue is reportable in some jurisdictions)
- Pregnancy: counsel postpartum vaccination planning (Dengvaxia or Qdenga where approved); no live attenuated vaccine in pregnancy
- Pre-vaccination serology (rapid IgG or ELISA) before Dengvaxia (mandatory); not required for Qdenga where approved

AVOID / contraindication checks:
- Avoid aspirin nsaids im injections anticoagulants in dengue bleeding risk (WHO 2009 + 2024; AAP Red Book 2024; FDA labels)
- Paracetamol max 60mg per kg per day pediatric or hepatitic dengue (WHO 2009; FDA acetaminophen label)
- Paracetamol max 4g per day adult dengue no hepatitis 2g per day if hepatitis (FDA label)
- No prophylactic platelet transfusion regardless of count only for active bleeding (WHO 2009 + 2024; Lye Lancet 2017 PMID 28283286)
- Fluid resuscitation titrate to Hct UOP clinical NOT MAP alone (WHO 2009 + 2024)
- Lactated ringers preferred first line over dextran 70 and HES due to bleeding risk (Wills NEJM 2005 PMID 16135832)
- HES restricted in many regions AKI coagulopathy signal (EMA 2018; FDA 2021)
- Dengvaxia CONTRAINDICATED in seronegative pre vaccination serology mandatory (CDC ACIP 2021 PMID 34978547; Sridhar NEJM 2018 PMID 29897841)
- Dengvaxia 3 dose schedule 0 6 12 months (FDA label)
- Dengvaxia contraindicated pregnancy severe immunocompromise live attenuated (FDA label)
- Qdenga not yet FDA approved as of 2026 05 15 (FDA — pending review)
- Qdenga 2 dose schedule 0 3 months where approved (EMA 2022)
- Qdenga contraindicated pregnancy severe immunocompromise live attenuated (EMA 2022)
- Dengue in pregnancy admit regardless of warning signs vertical transmission PPH risk (ACOG; Paixao Lancet ID 2016 PMID 26949028)
- Dengue third space mobilization recovery phase cautious diuresis furosemide only if pulmonary edema (WHO 2009 + 2024)
- Returning traveler fever broad ddx co test malaria typhoid lepto rickettsial chikungunya zika (CDC Yellow Book 2024)
- No corticosteroids in dengue not beneficial signal of harm (WHO 2009 + 2024; meta analyses)
- Tranexamic acid off label only id consult driven data emerging not standard (WHO 2024)
- Acyclovir iv hydration prevent crystalline nephropathy 1.5 to 2x maintenance (FDA label)
- Acyclovir dose adjust aki Cr x 1.5 2 q12h Cr x 2 3 q24h (FDA label)
- Norepinephrine titrate MAP but do not mask under resuscitation in dengue (SSC 2026; WHO 2009 + 2024)
- Doxycycline pediatric under 8 yo tooth staining warning balance against rickettsial risk (FDA label; CDC Yellow Book 2024)
- Colloid dextran 40 anaphylaxis monitor (FDA label)
- Furosemide cautious recovery phase only if pulmonary edema not prophylactic (WHO 2009 + 2024)

Monitoring

Regimen monitoring:
- Serial Hct + platelets q4-6h in critical phase (days 4-6); transition to recovery phase = Hct stable / falling + platelets recovering + clinical improvement
- Continuous vitals + cap refill + UOP + lactate during active resuscitation in severe dengue with shock (DSS); reassess Hct + clinical q1-2h
- Daily LFT + creatinine + coags + UOP in inpatient + ICU
- Daily reassessment of phenotype (febrile / critical / recovery) + drug actions + de-escalation as appropriate
- CBC + dengue NS1 + IgM serology + RT-PCR follow-up + co-test for malaria / typhoid / lepto / rickettsial in returning traveler
- Pre-vaccination serology (rapid IgG or ELISA) mandatory before Dengvaxia (CYD-TDV); confirm seropositive before 3-dose series at 0/6/12 mo
- Vaccine post-dose audit: Dengvaxia 3-dose at 0/6/12 mo; Qdenga 2-dose at 0/3 mo; lifetime serology baseline + future-trip risk counseling
- Recovery-phase fluid management: reduce IV fluids when Hct stable / falling + clinical improvement; cautious furosemide IF clinical pulmonary edema (NOT prophylactic)
- Pregnancy: maternal-fetal medicine consult + vertical transmission surveillance peripartum + PPH risk + neonatal dengue surveillance
- Travel-medicine counseling at follow-up: vector avoidance + DEET-containing repellent + permethrin-treated clothing + standing-water elimination + pre-trip vaccination decision
- Public health reporting per local regulations (dengue is reportable in some jurisdictions)

Setting (outpatient) monitoring:
- Daily warning-sign + CBC + tourniquet test review during days 3-7
- Phase transition (febrile → critical → recovery) monitoring
- Convalescent fatigue may last weeks
- Post-vaccine: Dengvaxia 3-dose audit at 0/6/12 mo; Qdenga 2-dose audit at 0/3 mo

Follow-up plan: Post-acute: convalescent fatigue may last weeks; lifetime homologous-serotype immunity + ~ 2 yr cross-protection against heterologous serotypes; counsel on **secondary heterologous infection ADE risk** for future trips to endemic regions; lifetime serology baseline documented for future vaccine + risk-management decisions; vaccine decision (Dengvaxia seropositive-only per CDC ACIP 2021; Qdenga where approved); post-severe-dengue follow-up: hepatitis recovery (LFT trend), AKI recovery (creatinine + GFR trend), myocarditis recovery (echo + ECG), encephalitis recovery (neuro + neuropsychology + rehabilitation). Pregnancy: postpartum surveillance for neonatal dengue + PPH recovery + MFM follow-up. Travel-medicine counseling: vector avoidance + DEET-containing repellent + permethrin-treated clothing + standing-water elimination + pre-trip vaccination decision for future endemic-area travel. Public health reporting per local regulations (some jurisdictions require dengue reporting) (WHO 2009 + 2024; CDC Yellow Book 2024)
- Close-out criterion: Follow-up + lifetime-serology counseling + vaccine plan + travel-medicine counseling delivered

Monitoring phase: Outpatient: daily return for warning-sign + CBC + tourniquet test during days 3-7 (critical-phase transition window); return precautions for new abdominal pain / persistent vomiting / clinical fluid accumulation / mucosal bleed / lethargy / restlessness / hepatomegaly. Inpatient: serial Hct + platelets q4-6h in critical phase; daily LFT + creatinine + coags + UOP; trend toward stable / falling Hct + recovering platelets + clinical improvement = transition to recovery phase + reduce IV fluids. ICU: continuous vitals + capillary refill + UOP + Hct q1-2h during active resuscitation; lactate trend; titrate fluid by Hct + UOP + clinical (NOT MAP alone); reassess for fluid overload as plasma leakage resolves. Recovery phase: reduce IV fluids when Hct stable / falling + clinical improvement; cautious diuresis with furosemide if pulmonary edema clinically. Vaccine post-dose: Dengvaxia 3-dose audit at 0/6/12 mo; Qdenga 2-dose audit at 0/3 mo; lifetime serology counseling for secondary-infection risk + future-trip planning (WHO 2009 + 2024; CDC ACIP 2021 PMID 34978547)

Disposition

Current setting: outpatient — Manage dengue without warning signs in immunocompetent adult / child / adolescent on paracetamol + ORS + daily return for warning-sign + CBC review during days 3-7 (critical-phase transition window); return precautions; vaccine decision (Dengvaxia seropositive-only ≥ 9 yo per CDC ACIP 2021; Qdenga any serostatus 4-60 yo where approved per EMA 2022); travel-medicine counseling (vector avoidance + DEET repellent + permethrin-treated clothing + standing-water elimination); post-illness follow-up + lifetime serology baseline + counseling on secondary-heterologous-infection ADE risk for future endemic-area travel (WHO 2009 + 2024; CDC Yellow Book 2024; AAP Red Book 2024; Halstead Lancet 2007 PMID 17993365)

Disposition criteria:
- Sustained recovery — fever resolved + rash resolving + platelet recovering + clinical improvement + family education delivered + travel-medicine counseling + vaccine decision documented + lifetime serology baseline + outpatient follow-up as indicated

Escalation triggers (move to higher acuity):
- Warning signs emerge → urgent ED + CBC + LFT + coags + admit for IV crystalloid maintenance
- Severe dengue features (shock, severe bleeding, severe organ failure) → urgent ED + ICU + crystalloid bolus
- Pregnancy + active disease → urgent ED + admit regardless of warning-sign status
- Dehydration with inability to maintain oral intake → urgent ED + IV fluids
- Persistent fever > 7 d → reassess for alternative etiology (bacterial co-infection, atypical course, alternative dx)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Severe dengue with shock (DSS — life-threatening) — narrow pulse pressure ≤ 20 mmHg, overt hypotension, cap refill > 2 s, cold extremities, tachycardia, decreased UOP; ICU + IV crystalloid bolus 10-20 mL/kg over 1 h (compensated) or 15-30 min (hypotensive); titrate by Hct + UOP + clinical (NOT MAP alone — over-titration to high MAP can mask under-resuscitation); colloid (dextran 40) 10 mL/kg for fluid-refractory; vasopressor (norepinephrine) for vasopressor-dependent per SSC 2026; avoid blanket 30 mL/kg sepsis bolus per dengue-specific cautious-fluid caveat (WHO 2009 + 2024; Wills NEJM 2005 PMID 16135832; SSC 2026)
- [LIFE_THREATENING] Severe dengue with severe bleeding (life-threatening) — GI / GU / intracranial / mucosal hemorrhage with hemodynamic instability; packed RBC transfusion for active bleeding (NOT prophylactic regardless of platelet count); cryoprecipitate / FFP if coagulopathy / low fibrinogen; tranexamic acid considered per ID consult for severe bleeding (data emerging, not yet standard); **NO prophylactic platelet transfusion regardless of count per WHO 2009 + Lye Lancet 2017 PMID 28283286** (RCT showed no reduction in bleeding); ICU + correct shock (WHO 2009 + 2024; Lye Lancet 2017 PMID 28283286)
- [LIFE_THREATENING] Severe dengue with severe organ dysfunction (life-threatening) — hepatitis (AST/ALT ≥ 1000; reduce paracetamol max-dose to 60 mg/kg/d pediatric / 2 g/d adult; avoid additional hepatotoxic drugs), encephalitis (altered mental status, seizures, focal deficits — HSV encephalitis is major treatable mimic; empiric IV acyclovir 10 mg/kg q8h pending HSV PCR per Tunkel IDSA encephalitis 2008), myocarditis (cardiac dysfunction, arrhythmia, troponin elevation — echo + ECG + ICU + avoid fluid overload), AKI (Cr × 1.5-3 baseline; CRRT if RRT-requiring); ICU + supportive + organ-specific (WHO 2009 + 2024; Tunkel IDSA encephalitis 2008)

Citations

- WHO 2009 Dengue Guidelines: Diagnosis, Treatment, Prevention and Control + WHO 2024 update — canonical three-phase pathophysiology + warning signs + severe-dengue criteria + fluid algorithm + platelet-transfusion threshold + vaccine guidance + CDC Yellow Book 2024 Dengue chapter + PAHO 2022 Dengue Clinical Management Guidelines + AAP Red Book current edition (2024 + 2026 floor) Dengue chapter + CDC ACIP Dengvaxia 2021 (PMID 34978547; seropositive-only ≥ 9 yo) + EMA / Takeda Qdenga 2022 (TAK-003 tetravalent live attenuated; any serostatus 4-60 yo where approved; not yet FDA-approved) + Bhatt Nature 2013 (global burden) + Halstead Lancet 2007 (ADE) + Simmons NEJM 2012 (review) + Sridhar NEJM 2018 (Dengvaxia post-hoc subgroup) + Biswal NEJM 2019 (TIDES TAK-003) + Tricou Lancet Glob Health 2024 (TAK-003 long-term) + Lye Lancet 2017 (NO prophylactic platelet) + Wills NEJM 2005 (LR preferred first-line) + Paixao Lancet ID 2016 (pregnancy meta-analysis) + ACOG Practice Advisory Dengue in Pregnancy + Tunkel IDSA encephalitis 2008 (empiric IV acyclovir) [PMID:23563266](https://pubmed.ncbi.nlm.nih.gov/23563266/)
- Cited evidence (PMID 17993365) [PMID:17993365](https://pubmed.ncbi.nlm.nih.gov/17993365/)
- Cited evidence (PMID 22494122) [PMID:22494122](https://pubmed.ncbi.nlm.nih.gov/22494122/)
- Cited evidence (PMID 29897841) [PMID:29897841](https://pubmed.ncbi.nlm.nih.gov/29897841/)
- Cited evidence (PMID 31693803) [PMID:31693803](https://pubmed.ncbi.nlm.nih.gov/31693803/)

Last reconciled with current guidelines: 2026-05-22.
References
  • WHO 2009 Dengue Guidelines: Diagnosis, Treatment, Prevention and Control + WHO 2024 update — canonical three-phase pathophysiology + warning signs + severe-dengue criteria + fluid algorithm + platelet-transfusion threshold + vaccine guidance + CDC Yellow Book 2024 Dengue chapter + PAHO 2022 Dengue Clinical Management Guidelines + AAP Red Book current edition (2024 + 2026 floor) Dengue chapter + CDC ACIP Dengvaxia 2021 (PMID 34978547; seropositive-only ≥ 9 yo) + EMA / Takeda Qdenga 2022 (TAK-003 tetravalent live attenuated; any serostatus 4-60 yo where approved; not yet FDA-approved) + Bhatt Nature 2013 (global burden) + Halstead Lancet 2007 (ADE) + Simmons NEJM 2012 (review) + Sridhar NEJM 2018 (Dengvaxia post-hoc subgroup) + Biswal NEJM 2019 (TIDES TAK-003) + Tricou Lancet Glob Health 2024 (TAK-003 long-term) + Lye Lancet 2017 (NO prophylactic platelet) + Wills NEJM 2005 (LR preferred first-line) + Paixao Lancet ID 2016 (pregnancy meta-analysis) + ACOG Practice Advisory Dengue in Pregnancy + Tunkel IDSA encephalitis 2008 (empiric IV acyclovir) — PMID:23563266
  • Cited evidence (PMID 17993365) — PMID:17993365
  • Cited evidence (PMID 22494122) — PMID:22494122
  • Cited evidence (PMID 29897841) — PMID:29897841
  • Cited evidence (PMID 31693803) — PMID:31693803