Dengue fever history and symptoms

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Alonso Alvarado, M.D. [2]


Dengue virus infection has a wide spectrum of clinical manifestations, ranging from asymptomic infection, to symptoms of non-severe disease (such as flu-like symptoms, fever, retro-orbital headache, fatigue, arthralgia, myalgia, nausea, vomiting, or lymphadenopathy), and to severe complications including signs of plasma leakage (such as pleural effusion or ascites), hemorrhagic tendencies (such as petechiae, ecchymoses, purpura, easy bruising at venipuncture sites, mucosal bleeding, gastrointestinal bleeding, hematemesis, or melena), and organ failure associated with shock.

History and Symptoms

Adapted from Dengue: guidelines for diagnosis, treatment, prevention and control. © World Health Organization 2009[1]
Warning Signs Requiring Strict Observation and Medical Intervention
Complications in Febrile, Critical, and Recovery Phases of Dengue
  • Febrile phase
  • Critical phase
  • Recovery phase

After an incubation period of 4–10 days, the illness begins abruptly and is followed by the three phases — the Febrile Phase, the Critical Phase, and the Recovery Phase.[2]

Symptoms Dengue Fever.png

Febrile Phase

  • These clinical features do not predict the severity of dengue fever. Therefore, it is crucial to monitor for warning signs and other clinical parameters in order to recognize progression to the critical phase.
  • The earliest abnormality in the complete blood count is leukopenia, which should alert the physician to a high probability of dengue. The platelet count usually begins to drop when the temperature is returning to normal.
  • When no rash is present, mild symptoms of dengue fever may be misdiagnosed as influenza or other viral infection. Travelers from endemic areas may inadvertently pass on dengue in their home countries, having not been properly diagnosed at the height of their illness. Patients with dengue can only pass on the infection through mosquitoes or blood products while they are still febrile.

Critical Phase

  • During the transition from the febrile to afebrile phase, patients without an increase in capillary permeability will improve without going through the critical phase. Instead of improving with the subsidence of fever, patients with increased capillary permeability may manifest with symptoms indicative of plasma leakage and enter what is termed the critical phase.
  • The critical phase is heralded by the development of warning signs. These patients become worse around the time of defervescence, when the temperature drops to 37.5–38°C or less and remains below this level, usually on days 3 through 8 of the illness. Progressive leukopenia (≤5000 cells/mm3) with a rapid decline in platelet count to about 100,000 cells/mm3 typically precedes plasma leakage and the capillary leak syndrome.

Recovery Phase

  • As the patient survives the 24–48 hours of the critical phase, a gradual reabsorption of fluid from the extravascular compartment takes place in the following 48–72 hours. Appetite returns, gastrointestinal symptoms abate, hemodynamic status stabilizes, and diuresis ensues.
  • The hematocrit normalizes or may be lower than the baseline value due to hemodilution. The white cell count usually starts to rise soon after defervescence, while the recovery of the platelet count is typically delayed.

Adapted from Dengue haemorrhagic fever: diagnosis, treatment, prevention and control. © World Health Organization 1997 [6]


  1. "Dengue: guidelines for diagnosis, treatment, prevention and control" (PDF).
  2. Thong, Meow-Keong (1998). "Dengue shock syndrome and acute respiratory distress syndrome". The Lancet. 352 (9141): 1712. doi:10.1016/S0140-6736(05)61496-1. ISSN 0140-6736.
  3. 3.0 3.1 Kalayanarooj, S.; Vaughn, D. W.; Nimmannitya, S.; Green, S.; Suntayakorn, S.; Kunentrasai, N.; Viramitrachai, W.; Ratanachu‐eke, S.; Kiatpolpoj, S.; Innis, B. L.; Rothman, A. L.; Nisalak, A.; Ennis, F. A. (1997). "Early Clinical and Laboratory Indicators of Acute Dengue Illness". The Journal of Infectious Diseases. 176 (2): 313–321. doi:10.1086/514047. ISSN 0022-1899.
  4. Mayxay, Mayfong; Phetsouvanh, Rattanaphone; Moore, Catrin E; Chansamouth, Vilada; Vongsouvath, Manivanh; Sisouphone, Syho; Vongphachanh, Pankham; Thaojaikong, Thaksinaporn; Thongpaseuth, Soulignasack; Phongmany, Simmaly; Keolouangkhot, Valy; Strobel, Michel; Newton, Paul N. (2011). "Predictive diagnostic value of the tourniquet test for the diagnosis of dengue infection in adults". Tropical Medicine & International Health. 16 (1): 127–133. doi:10.1111/j.1365-3156.2010.02641.x. ISSN 1360-2276.
  5. Srikiatkhachorn, Anon; Krautrachue, Anchalee; Ratanaprakarn, Warangkana; Wongtapradit, Lawan; Nithipanya, Narong; Kalayanarooj, Siripen; Nisalak, Ananda; Thomas, Stephen J.; Gibbons, Robert V.; Mammen, Mammen P.; Libraty, Daniel H.; Ennis, Francis A.; Rothman, Alan L.; Green, Sharone (2007). "Natural History of Plasma Leakage in Dengue Hemorrhagic Fever". The Pediatric Infectious Disease Journal. 26 (4): 283–290. doi:10.1097/01.inf.0000258612.26743.10. ISSN 0891-3668.
  6. "Dengue haemorrhagic fever: diagnosis, treatment, prevention and control" (PDF).