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Key Features

  • Travel or residence in an endemic area

  • Transmitted by the Aedes mosquito (present in the southern United States)

  • Failure to recognize and treat dengue hemorrhagic fever (DHF) may lead to dengue shock syndrome, which is defined by signs of circulatory failure and hypotension or shock, and has a high fatality rate (10%)

  • Neurologic complications such as encephalitis, myositis, myelitis, Guillain-Barré syndrome, and mononeuropathies are reported in 5–10%

Clinical Findings

  • Onset begins abruptly 4–7 days after transmission (range, 3–14 days) with

    • Fever, chills

    • Severe retro-orbital pain

    • Severe muscle and joint pain

    • Nausea, and vomiting

  • Erythema of the face and torso may occur early

  • Centrifugal maculopapular rash

    • Appears in half of the patients after 3–4 days

    • Described as "islands of white in a sea of red"

    • Can become petechial

    • Mild hemorrhagic signs (epistaxis, gingival bleeding, microscopic blood in stool or urine) may be noted

  • The illness lasts 5–7 days, although rarely fever may reappear for several additional days

  • Since there are four serotypes of dengue virus, multiple sequential infections can occur


  • Mild leukopenia and thrombocytopenia are common

  • Liver function tests are usually normal

  • Diagnosis is made by

    • Viral culture of plasma (50% sensitive up to the fifth day)

    • Presence of viral antigenemia (90% sensitive during the febrile phase of first infections)

    • Dengue PCR during the first 5 days

    • Presence of IgM-specific ELISA antibodies (70–80% sensitive at the sixth day)

    • Detection of a rise in type-specific antibody

  • DHF is defined by significant thrombocytopenia (< 100,000 platelets/μL, bleeding, and a plasma leak syndrome [hemoconcentration = hematocrit > 20% higher than baseline], hypoalbuminemia, and pleural or peritoneal effusions)


  • Avoid high-risk areas and use conventional mosquito avoidance measures

  • Oral rehydration and antipyretics should be given, avoiding nonsteroidal anti-inflammatory agents that affect platelet function

  • Recovery is complete without sequelae

  • The hemorrhagic syndrome requires prompt fluid therapy with plasma expanders and isotonic saline and close ICU monitoring

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