Skip to Main Content

We have a new app!

Take the Access library with you wherever you go—easy access to books, videos, images, podcasts, personalized features, and more.

Download the Access App here: iOS and Android

For further information, see CMDT Part 32-04: Viral Hemorrhagic Fevers

Key Features

Essentials of Diagnosis

  • Incubation period is 7–10 days

  • Sudden onset of high fever, chills, severe myalgias and arthralgias, headache, and retro-orbital pain

  • Severe dengue is defined by the presence of plasma leakage, hemorrhage, or organ involvement

  • Signs of hemorrhage such as ecchymoses, gastrointestinal bleeding, and epistaxis appear later in the disease

General Considerations

  • Four distinct serotypes can cause infection; infection with one serotype does not confer immunity to the others

  • Dengue is transmitted primarily from human to human by the bite of the Aedes mosquito

  • Healthcare-associated transmission (needlestick or mucocutaneous exposure) and vertical transmission occur rarely

  • WHO reports that dengue is currently endemic in more than 100 countries, mostly in tropical and subtropical regions, with about 70% of cases occurring in Asia

  • Dengue has been a nationally notifiable condition in the United States since 2010, but although it is endemic in northern Mexico, US outbreaks are uncommon

  • As of September 1, 2021, 32 dengue cases had been reported in 2001 in the United States and 367 in US territories (primarily Puerto Rico)

  • Case numbers have increased over the last 2 decades; this surge of cases is associated with climatic factors, travel, and urbanization

  • When the virus is introduced into susceptible populations, usually by viremic travelers, epidemic attack rates range from 50% to 70%

Clinical Findings

Symptoms and Signs

  • Incubation period is usually 7–10 days

  • After the incubation period, febrile phase begins abruptly with

    • Nonspecific symptoms

    • High fever

    • Chills

    • Facial flushing

    • Malaise

    • Retroorbital eye pain

    • Generalized body pain

    • Arthralgia

  • Some patients might have maculopapular rash, sore throat, and conjunctival injection

  • Not all patients have all symptoms or fever

  • Mild hemorrhagic manifestations can be seen

  • Most of the patients will recover and fever is usually cleared by day 8

  • A subset of patients may progress to severe dengue, which is defined by the presence of plasma leakage, hemorrhage, or organ involvement

    • Plasma leakage may be indicated by

      • Hematocrit drop

      • Increasing liver size

      • Persistent vomiting

      • Severe abdominal pain

    • Signs of hemorrhage such as ecchymoses, gastrointestinal bleeding, and epistaxis appear

    • Severe organ involvement may develop such as hepatitis, encephalitis, and myocarditis

  • Shock develops when a critical volume of plasma is lost through leakage; the following should raise concern for shock:

    • Decrease in the level of consciousness

    • Hypothermia

    • Hypoperfusion resulting in metabolic acidosis

    • Progressive organ impairment

    • Disseminated intravascular coagulation leading to severe hemorrhage

  • Acute kidney injury in dengue largely occurs with shock syndrome and has a high mortality

Differential Diagnosis

  • Chikungunya

  • Arboviral encephalitides

  • Influenza

  • Malaria


  • Leukopenia is characteristic

  • Elevated transaminases are found frequently

  • Thrombocytopenia, fibrinolysis, and hemoconcentration occur more often in the hemorrhagic form of the disease

  • Erythrocyte sedimentation ...

Pop-up div Successfully Displayed

This div only appears when the trigger link is hovered over. Otherwise it is hidden from view.