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Clinical features

Last reviewed dd mmm yyyy. Last edited dd mmm yyyy

Authoring team

Infection by any of the four dengue serotypes may lead to symptomatic infections or asymptomatic seroconversion (1)

  • asymptomatic infection
    • around half of patients with dengue infection have no clinical signs or symptoms of disease.
  • symptomatic infection
    • is a systemic and dynamic disease with a wide clinical spectrum that includes both severe and non severe clinical manifestations
    • severe disease usually follows three phases – febrile, critical and recovery
    • the severity of the disease usually becomes apparent around defervescence e.g. – during the transition from the febrile to afebrile phase (around the time of the onset of the critical phase)
    • can be divided into
      • undifferentiated fever
        • presents with fever and mild non-specific symptoms which may mimic other viral infections
        • do not meet case definition criteria for DF
        • typically young children or those experiencing their first infection (may also occur during a secondary infection)
        • usually recover fully without need for hospital care
      • classic dengue fever (DF)
      • more severe forms of the disease - haemorrhagic fever (DHF) and dengue shock syndrome (DSS) (1,2)

Abrupt onset of symptoms occur after an incubation period of 3-14 days (average 7 days).

  • fever
    • characteristic feature of the infection with high spikes of 39.4-40.5°C
    • maybe seen as biphasic with a fluctuating body temperatures or as low grade fever over five to seven days
    • may result in febrile seizures or delirium in young children
  • aches and pains
    • frequent backache, arthralgia, myalgia, and bone pain are common
    • constant headache seen towards the front of the head is typical which resolves within a few days
    • severe retro-orbital pain with eye movement or with a little pressure applied to the eyeball
  • gastrointestinal symptoms
    • anorexia, nausea or vomiting, epigastric discomfort or pain
    • lack of appetite or changes to taste sensation
  • lethargy or restlessness
  • collapse, or dizziness
  • upper respiratory tract symptoms such as cough, sore throat may atypically occur in mild infection (3)

Signs present in dengue infection are:

  • diffuse skin flushing of the face, neck, and chest
    • on day 3 or 4 of the fever, skin flushing may progress into maculopapular or rubelliform rash
    • blanching of the skin may be present
    • rash fades with time and appear as pallid areas during the convalescent phase
  • haemorrhagic signs
    • petechiae, purpura
    • positive tourniquet test
      • record patient’s blood pressure
      • inflate the cuff to a point midway between SBP and DBP and maintain for 5 minutes
      • the test is positive when 10 or more petechiae per 1 square inch appear in the forearm (below antecubital fossa)
      • epistaxis, gingival bleeding, haematemesis, melaena, vaginal bleeding (in women of childbearing age), or bleeding from a venepuncture site indicates major haemorrhages
    • these signs may be observed in either dengue fever or dengue haemorrhagic fever.
  • heaptomegaly
  • ascites, postural dizziness, or pleural effusion – indicates plasma leakage seen in dengue haemorrhagic fever
  • circulatory collapse – supports a diagnosis of dengue shock syndrome
    • cold clammy skin
    • rapid and weak pulse with narrowing of pulse pressure <20 mm Hg with decreased diastolic pressure
    • postural drop of blood pressure >20 mm Hg
    • capillary refill time greater than three seconds
    • reduced urine output (3)


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