Once the most awaited rains hit the ground, most viral fevers knock at the Hospital doors. The one among them that glares and stands out is Dengue Fever. Most of us are preoccupied and over diagnose Dengue fever, which to some extent is justified for not missing Severe Dengue hemorrhagic fevers.
The fundamentals are most of these viral fevers are self-limiting and do not require specific medication apart from symptomatic, Supportive Care. And importantly, as we all know Antibiotic (antibacterial) medications have no role in viral infections unless complicated by Secondary infections.
The fact that not all cases of dengue fever complicate or progress to hemorrhagic fever or shock syndrome, most of the stable patients do not require extensive evaluations at initial presentation. And, Complications start after the patient becomes afebrile and starts feeling better, usually on day 4 or 5. A simple approach is to give symptomatic management and get a CBP on day 3 or 4. If there is thrombocyto-penia, further evaluation is necessary with NS1, Dengue Ig. M & Ig G, PCV, LFT, Renal parameters, X-ray Chest, USG abdomen.
The Dengue NS1 Ag Strip can be used as a bedside diagnostic test to support a diagnosis of acute dengue, though it seemed to be less sensitive when used in patients within the first day from illness onset.
Dengue Ig. M & Ig G (ELISA) confirms acute (Dengue Ig M +ve & Ig G -ve), chronic / the past (Dengue Ig M -‘ve & Ig G +ve), Secondary (Dengue Ig M +ve & Ig G +ve) phases of Viral fever.
Mild elevation in LFTs (AST &ALT) is expected but usually below 500, higher values are cautioned for further evaluation to rule out the alternative diagnosis.
The patient needs hospitalized management once the platelets fall below 1 Lakh or have other complications like hypertension, a capillary leak occurs. Most patients recover with simple Supportive Care. PCV guides us in fluid management and impending shock syndrome. Once Below 1 lakh, 12th hourly platelet monitoring is advisable, along with close monitoring of bleeding manifestation.
Risk of major spontaneous bleeding occurs below 20,000 and recommendation for platelet transfusion prophylactically is platelet count less than 10,000. So, there is no role for prophylactic platelet or other blood product transfusion in stable patients with higher platelet counts.
In fact, overzealous platelet transfusions can complicate the clinical picture with complications like TRAIL.
Patient reassurance and Conscious Clinical assessment to pick up early warning signs of bleeding tendency, Shock syndrome and timely intervention are all that is needed.If these warning Signs are present, the patient should be monitored more frequently and if possible in High Dependency Units.
To Conclude, most viral fevers including dengue are self-limiting in nature and do not require more than close monitoring along with symptomatic management.
Contributed by DR. T.G.KIRAN BABU
MD (Internal Medicine), DIDM, FIDM (CMC)