Paeds · infectious-diseases
Dengue and other arboviral infections
Also known as Dengue fever · Dengue haemorrhagic fever · Dengue shock syndrome · Severe dengue · Zika virus disease · Congenital Zika syndrome · Chikungunya
Fellowship guide to dengue and other paediatric arboviral infections: Aedes-borne dengue, Zika and chikungunya; the WHO 2009 classification and warning signs; the reversible capillary plasma leak that defines severe dengue; serial haematocrit and platelet monitoring; titrated isotonic crystalloid through the critical phase around defervescence; the harmful-no-bolus lesson; the CYD-TDV and TAK-003 vaccines; congenital Zika syndrome; and chikungunya arthropathy in children.
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Target exams
Red flags
- Any child with fever and travel to, or residence in, a dengue-endemic area in the preceding two weeks
- Defervescence with deterioration: the child worsens as the fever falls, signalling the plasma-leak critical phase
- Narrow pulse pressure below 20 mmHg, cold peripheries, or delayed capillary refill indicating dengue shock
- Persistent vomiting, abdominal pain, lethargy, mucosal bleeding, or hepatomegaly as WHO warning signs
- Rising haematocrit with falling platelets indicating evolving severe dengue
- Severe bleeding, altered consciousness, jaundice, or respiratory distress from pleural effusion signalling organ-impairment severe dengue
- Microcephaly, intracranial calcifications, or arthrogryposis in an infant whose mother had a rash illness in pregnancy suggesting congenital Zika syndrome
- High fever, maculopapular rash and severe small-joint arthralgia in an outbreak region suggesting chikungunya
Life stages
Care settings
Clinical exam formats
Board mappings
- Takes a travel and Aedes-exposure history in any febrile child
- Recognises dengue warning signs and the critical phase around defervescence
- Initiates group-based dengue management and avoids aspirin/NSAIDs
- Justifies fluid strategy by haematocrit trend and perfusion in severe dengue
- Differentiates dengue from Zika, chikungunya, malaria and sepsis
- Counsels on dengue vaccine indications and the serostatus caveat
- Recognition and resuscitation of dengue shock in a returned traveller
- Diagnosis of imported dengue in a non-immune febrile child
- Safety-netting and disposition for a child with dengue warning signs
- Bedside assessment and serial monitoring of a child with dengue
- Communication of the fluid plan and warning signs to the family
- Counselling a pregnant adolescent exposed to Zika virus
- Level 1: Recognises fever with rash and travel as a red flag
- Level 2: Diagnosis and initial management of dengue and the arboviruses
- Level 3: Management of severe dengue shock and congenital Zika syndrome
- Dengue serotypes and antibody-dependent enhancement
- WHO 2009 dengue classification and warning signs
- Congenital Zika syndrome phenotype and chikungunya arthropathy
- History and examination of the febrile returned traveller
- Structured assessment of a child with shock and a narrow pulse pressure
- Communication of the dengue fluid plan and family safety-netting
- Diagnosis of dengue by NS1 antigen and serology
- Fluid management of severe dengue and avoidance of harmful boluses
- Recognition of congenital Zika syndrome in the infant
- Recognition and resuscitation of the child with dengue shock
- Risk-stratified outpatient vs inpatient dengue management
- Travel and outbreak history in the differential of paediatric fever
- Imported dengue in the Canadian paediatric returned traveller
- Severe dengue fluid management and access pathways
- Congenital Zika and travel-medicine counselling
Overview & Definition
Dengue is a mosquito-borne flavivirus illness that has become the most important arboviral cause of severe paediatric disease worldwide, with an estimated 100 to 400 million infections and around half the world's population now living at risk.[1] In children the dangerous form is not the fever itself but a narrow, reversible window of capillary plasma leakage that can tip a previously well child into shock over a matter of hours, so the clinical task is less to treat the fever and more to escort the child safely through that leak.[2]
Three Aedes-borne viruses dominate paediatric practice: dengue, Zika and chikungunya. They share a vector and an early febrile-rash presentation, but each has a distinct signature that the examiner expects you to separate. Dengue's signature is plasma leakage and shock; Zika's is injury to the developing fetal brain; and chikungunya's is severe, relapsing small-joint arthritis.[3]
References15ShowHide
- [1]Bhatt S, Gething PW, Brady OJ, et al. The global distribution and burden of dengue. Nature, 2013.PMID 23563266
- [2]Guzman MG, Harris E Dengue. Lancet, 2015.PMID 25230594
- [3]Wilder-Smith A, Ooi EE, Horstick O, Wills B Dengue. Lancet, 2019.PMID 30696575
- [4]Alexander N, Balmaseda A, Coelho IC, et al. Multicentre prospective study on dengue classification in four South-east Asian and three Latin American countries. Trop Med Int Health, 2011.PMID 21624014
- [5]Hadinegoro SR, Arredondo-García JL, Capeding MR, et al. Efficacy and Long-Term Safety of a Dengue Vaccine in Regions of Endemic Disease. N Engl J Med, 2015.PMID 26214039
- [6]Biswal S, Reynales H, Saez-Llorens X, et al. Efficacy of a Tetravalent Dengue Vaccine in Healthy Children and Adolescents. N Engl J Med, 2019.PMID 31693803
- [7]Tricou V, Yu D, Reynales H, et al. Long-term efficacy and safety of a tetravalent dengue vaccine (TAK-003): 4.5-year follow-up of a randomised controlled trial. Lancet Glob Health, 2024.PMID 38245116
- [8]World Health Organization Dengue vaccine: WHO position paper, September 2018 - Recommendations. Vaccine, 2019.PMID 30424888
- [9]Sangkaew S, Ming D, Boonyasiri A, et al. Risk predictors of progression to severe disease during the febrile phase of dengue: a systematic review and meta-analysis. Lancet Infect Dis, 2021.PMID 33640077
- [10]Thanachartwet V, Wattanathum A, Oer-Areemitr N, et al. Diagnostic accuracy of peripheral venous lactate and the 2009 WHO warning signs for identifying severe dengue in Thai adults: a prospective cohort study. BMC Infect Dis, 2016.PMID 26832147
- [11]Rasmussen SA, Jamieson DJ, Honein MA, Petersen LR Zika Virus and Birth Defects - Reviewing the Evidence for Causality. N Engl J Med, 2016.PMID 27074377
- [12]Paixao ES, Cardim LL, Brickley EB, et al. Mortality from Congenital Zika Syndrome - Nationwide Cohort Study in Brazil. N Engl J Med, 2022.PMID 35196428
- [13]Coyne CB, Lazear HM Zika virus - reigniting the TORCH. Nat Rev Microbiol, 2016.PMID 27573577
- [14]Fischer M, Staples JE Notes from the field: chikungunya virus spreads in the Americas - Caribbean and South America, 2013-2014. MMWR Morb Mortal Wkly Rep, 2014.PMID 24898168
- [15]Carrillo FAB, Ojeda S, Balmaseda A, et al. Comparison of dengue, chikungunya, and Zika among children in Nicaragua across 18 years: a single-centre cohort study. Lancet Child Adolesc Health, 2025.PMID 40774783