This paper is aimed at highlighting some of the dilemmas faced by clinicians in the management of adult patients with dengue and my views in resolving these issues. Even though early diagnosis and prompt fluid therapy are central to reduce morbidity and mortality in dengue, achieving these goals are contentious issues and are often hampered by the limited access to expensive laboratory data in most developing countries which would enable a rapid and accurate diagnosis. My viewpoint on overcoming these dilemmas is to make an early diagnosis on the clinical features, and apply clinical predictors of disease severity in selecting patients for interventions. In this regard, diffuse blanching erythema in a patient with features of a viral fever during dengue epidemics would suffice to diagnose and treat the patient as a dengue case. Laboratory confirmatory data are expensive, not readily available and could delay treatment. Fluid therapy and intervention modalities for thrombocytopaenia should be judged clinically on an individual basis rather than the blind, strict adherence to theoretical fluid regimens with the potential risk of fluid overloading. Capillary refill time, pulse pressure, cervical lymphadenopathy, and changes in the sensorium are useful clinical parameters for selection of patients for intervention as well as subtle adjustments and termination of fluid therapy. A practically feasible step-wise approach to dengue management is described in this paper.
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