On this page
Quick Reference
Overview and Recommendations
Background
- •Recognize dengue as a systemic viral infection caused by four distinct serotypes (DENV-1, 2, 3, and 4), where DENV-2 is frequently associated with the highest virulence and risk of severe outbreaks.
- •Understand the transmission cycle involving female Aedes mosquitoes, which acquire the virus from viremic humans and can also transmit the virus vertically to their larvae, allowing environmental persistence during dry seasons.
- •Identify the primary risk factor for severe disease as secondary infection with a different serotype; this triggers antibody-dependent enhancement (ADE), where non-neutralizing antibodies facilitate viral entry into macrophages, causing a massive cytokine release.
- •Note the expanding geographic range of the vectors, with Aedes albopictus facilitating transmission in temperate regions like Southern Europe, while Aedes aegypti remains the dominant urban vector in tropical hyperendemic zones.
- •Consider the impact of comorbidities such as , , and , which significantly increase the risk of symptomatic presentation and progression to severe organ involvement.
Evaluation
- •Suspect dengue in any patient with acute high-grade fever (≥38°C) who has lived in or traveled to an endemic region (e.g., Southeast Asia, Puerto Rico, Mexico) within the last 14 days.
- •Ask about the classic triad of "breakbone fever": severe frontal headache, retro-orbital pain, and intense myalgias or arthralgias, often following a biphasic or "saddleback" fever pattern.
- •Examine the skin for the pathognomonic "isles of white in a sea of red" rash—a confluent erythematous exanthema with small circular areas of skin sparing—and check for petechiae on the extremities.
- •Perform the Tourniquet Test (TT) to assess capillary fragility: inflate a blood pressure cuff to the mean arterial pressure [(Systolic + Diastolic) / 2] for 5 minutes; a count of ≥10–20 petechiae per square inch on the ventral forearm is positive.
- •Monitor for "Warning Signs" during the transition from the febrile to the critical phase (typically days 3–7), including abdominal pain or tenderness, persistent vomiting, mucosal bleeding, and lethargy.
- •Order a (CBC) daily to track the characteristic progression of leukopenia (WBC <5,000 cells/mm³), followed by a rapid drop in platelet count and a rising hematocrit indicating plasma leakage.
- •Obtain NS1 antigen and/or RT-PCR for definitive diagnosis if the patient presents within the first 5 days of symptom onset (the viremic phase).
- •Order IgM and IgG serology if the patient presents after day 5 of illness; note that a four-fold rise in IgG titers in paired sera is diagnostic of recent infection.
- •Utilize bedside ultrasonography to detect subclinical plasma leakage, specifically looking for gallbladder wall thickening, , and pleural effusions (often appearing first on the right side).
- •Rule out co-infections such as , , and , particularly in regions where these pathogens overlap, as co-infection can exacerbate anemia and organ dysfunction.
- •Assess for neurological complications, including cerebellar , , or signs of if the patient exhibits motor weakness or altered consciousness.
- •Monitor respiratory mechanics closely if plasma leakage is suspected; an FVC < 15 mL/kg should prompt consideration for mechanical ventilation due to massive effusions or pulmonary edema.
Management
- •Administer Acetaminophen (Paracetamol) for fever and pain control, maintaining a maximum dose of 4g/day in adults; strictly avoid Aspirin and NSAIDs (e.g., Ibuprofen) due to the risk of gastritis and platelet dysfunction.
- •Encourage aggressive oral hydration in the ambulatory setting, aiming for approximately 2 liters of fluid per day (e.g., oral rehydration salts, fruit juices) to reduce the risk of hospitalization.
- •Initiate IV fluid therapy with isotonic crystalloids (e.g., Lactated Ringer's or Normal Saline) at 5–7 mL/kg/hour for patients with warning signs who cannot maintain oral intake.
- •Manage (DSS) with an immediate IV bolus of isotonic crystalloid at 10–20 mL/kg over 15–30 minutes, followed by reassessment of hemodynamic status.
- •Consider colloid boluses (e.g., 5% albumin) in patients with refractory shock or those with massive where crystalloids may worsen extravascular fluid accumulation.
- •Monitor hematocrit every 6–12 hours during the critical phase; a rising hematocrit despite fluid resuscitation suggests ongoing plasma leakage and requires an increase in fluid rate.
- •Avoid prophylactic platelet transfusions even in cases of severe thrombocytopenia; reserve transfusions for patients with clinically significant, life-threatening hemorrhage.
- •Delay elective surgeries or delivery in pregnant patients until the critical phase has passed to minimize the risk of massive maternal hemorrhage.
- •Administer IVIG 2 g/kg as a single infusion in pediatric patients who develop -like features (e.g., coronary artery aneurysms) post-dengue.
- •Refer patients to intensive care if they exhibit severe plasma leakage leading to respiratory distress, severe organ impairment (AST/ALT ≥1000 U/L), or impaired consciousness.
- •Monitor for fluid overload during the recovery phase; as third-spaced fluid is reabsorbed, decrease IV fluids and watch for signs of pulmonary edema or heart failure.
- •Discharge patients only when they have been afebrile for 48 hours without antipyretics, show a rising platelet count, and have stable hematocrit levels with improving clinical symptoms.
- •Counsel patients on the use of the Dengvaxia vaccine only if they have laboratory-confirmed prior dengue infection, as it may increase the risk of severe disease in seronegative individuals.
Board Review — High Yield
- •Breakbone fever — Common name for dengue due to severe myalgia and arthralgia.
- •Isles of white in a sea of red — Classic description of the confluent erythematous rash with skin sparing.
- •Antibody-Dependent Enhancement (ADE) — Mechanism where secondary infection with a different serotype leads to more severe disease.
- •Tourniquet Test — Bedside marker for capillary fragility; positive if ≥10-20 petechiae per square inch.
- •Critical Phase — Occurs at the time of defervescence (fever drop), which is when plasma leakage and shock are most likely.
- •NS1 Antigen — Viral protein detectable in the blood from day 1 of symptoms, used for early rapid diagnosis.
- •Hematocrit/Platelet Divergence — A rising hematocrit with a falling platelet count is a hallmark of the critical phase.
- •Dengvaxia — Vaccine only recommended for those with evidence of prior dengue infection to prevent ADE-like reactions.
Deep Dive — Evidence Details
Etiology and Triggering Factors
- ▸Dengue is caused by DENV-1, DENV-2, DENV-3, or DENV-4 and is transmitted by Aedes mosquitoes, particularly Aedes aegypti.[174][115]
- ▸Imported infections can initiate local outbreaks where competent vectors and susceptible populations are present.[103]
- ▸Serotype and genotype replacement or co-circulation, especially involving DENV-3, DENV-4, and emerging lineages, can reshape outbreak risk and population immunity.[106][107][172][176]
- ▸Secondary infection and pre-existing immunity are major modifiers of disease expression and diagnostic interpretation.[108][109][111]
- ▸Seasonality, unusual seasonal extension, climate variability, and El Niño conditions may alter transmission, but no universal climatic threshold is established in the supplied evidence.[112][172][173][175]
- ▸Dengue may co-circulate or co-infect with other arboviruses and may occasionally be detected alongside another pathogen responsible for severe illness.[105][171][173]
Etiologic agent
Dengue is caused by dengue virus (DENV), an Aedes-borne orthoflavivirus comprising four antigenically distinct serotypes—DENV-1, DENV-2, DENV-3, and DENV-4.[174]D The principal documented vector in the supplied evidence is Aedes aegypti, including in highland areas of southwestern Saudi Arabia where molecular entomology confirmed its occurrence alongside acute human infection.[115] DENV shares vectors and overlapping clinical manifestations with chikungunya virus (CHIKV), and dengue may therefore be difficult to distinguish clinically from CHIKV, Zika virus, and other arboviral infections without laboratory testing.[105][117]D[173]D
Transmission and geographic amplification
Transmission is amplified when infected people introduce DENV into areas containing competent Aedes vectors and susceptible human populations. In China, imported infections repeatedly preceded local outbreaks during 2005–2023, although the country had not established stable, continuous local transmission during the period reviewed.[103] Surveillance from Saudi Arabia similarly supports active endemic transmission, including in highland governorates of the Jazan region; among 182 febrile patients tested in that study, 15.9% (29/182) had RT-qPCR-confirmed acute dengue infection.[115] Population-level evidence from Guinea demonstrated geographically distributed exposure to dengue and other arboviruses in a nationwide survey, confirming that arboviral circulation is not restricted to recognized outbreak settings.[169]
Global and regional spread is influenced by vector expansion, globalization, and climate-related environmental change.[173]D In Mexico, modelling and surveillance identified substantial spatial and year-to-year variation in DENV transmission intensity, with potentially important differences among the four serotypes.[112]C National surveillance from 2020–2024 documented an almost fivefold increase in reported dengue cases and transmission extending into unusual winter months from late 2023, indicating that seasonal timing can shift.[172]D In the Caribbean, laboratory surveillance from 2018–2024 showed temporal and seasonal variation in dengue and other arboviruses, although interpretation was limited because the dataset consisted of samples submitted for testing rather than a population-based incidence denominator.[170]
Serotype circulation and viral evolution
DENV serotypes circulate sequentially or concurrently, and the predominant serotype can change across locations and years. In Mexico, DENV-2 predominated until 2022, DENV-1 peaked in 2021, and DENV-3 increased thereafter.[172]D In Thailand, DENV-4 resurged during 2018–2024 within a hyperendemic setting where serotype predominance shifts cyclically and multiple serotypes co-circulate.[176]D Saudi Arabian molecular and serological surveillance likewise examined three decades of serotype dynamics and viral evolution, demonstrating the value of combining sequence data with epidemiologic surveillance to characterize circulating lineages.[106] In Myanmar, DENV-3 genotype III predominated before 2017, whereas genotype I emerged after 2017 and subsequently co-circulated with genotype III.[107]
Emergence of a genotype into a population with limited prior exposure may alter antibody recognition and the balance between neutralization and enhancement. In pediatric Myanmar samples, sera collected in 2004 showed reduced neutralization and higher in-vitro antibody-dependent enhancement (ADE) against the later-emerging DENV-3 genotype I; samples collected during 2017–2019 showed responses consistent with subsequent exposure and co-circulation.[107] These findings support viral genetic change and population immune history as interacting determinants of dengue epidemiology, but they do not establish that any single genotype invariably causes more severe disease.[107]
Host immunity and secondary infection
A major biological trigger for clinically important dengue is infection in a host with pre-existing, but not fully protective, DENV immunity. Sequential infections with different serotypes can produce secondary dengue and may influence clinical expression, diagnostic performance, and the distribution of circulating serotypes.[109] In Misiones, Argentina, analysis of 976 serum samples from outbreaks in 2016, 2019, and 2024 evaluated the increasing frequency of secondary infections and their relationship to severity markers and direct diagnostic results.[109] The supplied evidence supports secondary infection as an important epidemiologic and clinical modifier, but does not justify treating every secondary infection as severe.[109]
Population immunity is also shaped by vaccination and prior natural infection. Long-term follow-up of the chimeric yellow fever tetravalent dengue vaccine (CYD-TDV) in Indonesia assessed neutralizing antibodies against all four serotypes and dengue incidence 10 years after vaccination.[111] Vaccine safety and benefit depend on baseline serostatus and serotype-specific immune protection; the absence of a validated correlate of protection remains a limitation for evaluating vaccine efficacy and safety, particularly in DENV-naive individuals.[108] Accordingly, vaccination status, previous infection, and the infecting serotype should be considered when interpreting susceptibility and outbreak risk.[108][111]
Environmental and outbreak triggers
Outbreaks may be promoted by climatic variability and seasonal conditions that affect mosquito abundance, survival, and human–vector contact, although the supplied studies do not quantify a single universal climatic threshold.[112]C[173]D A strong El Niño forecast for 2026–2027 was specifically identified as a preparedness concern in Latin America because of anticipated increased risk in populations with limited DENV-3 immunity.[175]D Public-health interventions can also modify observed transmission: Thailand’s COVID-19-era measures may have affected dengue detection, transmission, and serotype dynamics.[176]D
Finally, apparent dengue outbreaks may include co-circulating or co-infecting pathogens. DENV–CHIKV dual positivity has been evaluated globally in settings with shared vectors and overlapping symptoms.[105] A fatal returning traveler had low-level DENV RNA and positive NS1 antigen together with disseminated velogenic avian orthoavulavirus 1 infection, illustrating that detection of DENV does not always prove it is the sole cause of a fulminant febrile illness.[171]C
| Factor | Evidence and relevance |
|---|---|
| DENV serotype | Four serotypes—DENV-1 to DENV-4—cause dengue; serotype predominance varies geographically and over time.[174]D[172]D |
| Vector exposure | Aedes-borne transmission is documented, with Aedes aegypti identified in Saudi Arabia.[105][115] |
| Importation | Imported cases repeatedly preceded local Chinese outbreaks during 2005–2023.[103] |
| Secondary infection | Sequential outbreaks and prior infection reshape immunity, clinical expression, and diagnostic performance.[109] |
| Viral evolution | DENV-3 genotype I emerged and co-circulated with genotype III in Myanmar; DENV-4 resurged in Thailand.[107][176]D |
| Climate and seasonality | Transmission intensity and seasonality vary; Mexico experienced winter transmission extension, and El Niño is a preparedness concern.[112]C[172]D[175]D |
| Co-circulating infections | CHIKV and other arboviruses overlap clinically with dengue; co-infection or alternative causes must be considered.[105][171]C[173]D |
History and Physical Examination
- ▸Define fever onset precisely; surveillance criteria used **≥38 °C on two of three consecutive days**, with molecular sampling preferably within **5 days** of onset. [26]
- ▸Do not assume that fever is malaria, especially in endemic regions; dengue, malaria and co-infections may coexist. [41][110][124][125][133]
- ▸Screen systematically for plasma leakage, shock, bleeding, respiratory compromise, renal dysfunction, cardiac involvement and neurologic complications. [129][131][122]
- ▸Fever **>38.3 °C beyond illness day 7** is associated with severe disease in hospitalized children with dengue warning signs or severe dengue. [130]
- ▸Older adults may have fewer or attenuated symptoms despite more severe laboratory deterioration. [127]
Initial history
Dengue should be considered in any patient with an acute febrile illness who lives in, or has recently travelled to, a dengue-endemic area. In returning travellers, document destination, dates of travel, mosquito exposure, illness onset, and other infectious exposures; one hospital-based study evaluated fever beginning within 30 days of return from tropical or subtropical regions and confirmed dengue in 4.0% of patients. [128][134] Dengue is an important alternative diagnosis in settings where fever is routinely attributed to malaria, including sub-Saharan Africa and South Asia, and dengue–malaria co-infection can occur. [41]D[110]C[124]C[125][133]
Record the date and time of fever onset, maximum measured temperature, fever pattern, antipyretic use, fluid intake and urine output. In clinical surveillance, fever was defined as ≥38 °C on two of three consecutive days, and diagnostic blood sampling for molecular testing was preferably performed within 5 days of fever onset. [26] Ask specifically about headache, retro-orbital pain, myalgia, arthralgia, rash, nausea, vomiting, abdominal pain, mucosal bleeding, lethargy, dyspnoea, chest discomfort, confusion, seizures and reduced urine output. The clinical phenotype varies by outbreak, serotype, age and setting; lower-respiratory symptoms were prominent in a DENV-4 outbreak, with pulmonary symptoms in 31.3% of hospitalized patients, including cough, lower-respiratory infection and chest distress. [45]D[104][177]C
Identify warning symptoms and their timing, particularly persistent vomiting, increasing abdominal pain, mucosal bleeding, dizziness or syncope, altered mental status, dyspnoea, oliguria and rapidly worsening weakness. Establish whether symptoms worsen as fever resolves, because deterioration may occur around the transition from the febrile phase. Prolonged fever is not typical of an uncomplicated course: in a hospitalized pediatric cohort with warning signs or severe dengue, fever >38.3 °C beyond illness day 7 occurred in 11.06% and was associated with severe disease and immune dysregulation. [130]
Document age, pregnancy status, immune status, previous dengue infection or vaccination, and comorbidities including cardiovascular, renal, hepatic, metabolic and hematologic disease. Older adults may have attenuated or atypical symptoms despite more severe laboratory evolution and worse outcomes; in one study, older age was defined as ≥60 years. [127] Ask about recent SARS-CoV-2 infection or exposure where dengue and COVID-19 co-circulate, because prior SARS-CoV-2 exposure has been investigated as a possible modifier of dengue immune responses, although available evidence is exploratory. [43]D
Physical examination
Assess general appearance, mental status, hydration, perfusion and respiratory effort. Measure temperature, heart rate, blood pressure, respiratory rate and oxygen saturation, and repeat measurements when the patient is deteriorating. Examine for postural symptoms, narrow pulse pressure, cool extremities, delayed capillary refill, tachypnoea, hypoxaemia and signs of shock. Inspect the skin and mucosa for flushing, exanthem, petechiae, ecchymoses, conjunctival injection and bleeding from the nose or gums. Examine the abdomen for tenderness, hepatomegaly, ascites or other evidence of plasma leakage, and assess lung fields for reduced air entry or crackles.
Evaluate for fluid accumulation, including pleural effusion and ascites. Polyserositis, particularly pleural effusion and/or ascites, was associated with mortality in a DENV-3 outbreak, even when severe thrombocytopenia was absent. [131] Renal dysfunction was also associated with fatal disease in that cohort. [131] Therefore, urine output, peripheral perfusion, respiratory status and volume tolerance should be assessed serially rather than relying on platelet count alone. [131]
Perform a focused neurologic examination, including orientation, behaviour, level of consciousness, cranial nerves, motor and sensory function, reflexes, gait when safe, and assessment for meningism. Seizures were present in all patients who died in the cited DENV-3 cohort, and transverse myelitis is a rare reported dengue-associated complication that may cause weakness, sensory disturbance or sphincter dysfunction. [131][122]C New focal deficits, a sensory level, urinary retention or progressive weakness require urgent evaluation for neurologic complications. [122]C
Assess for cardiac involvement when there is chest pain, dyspnoea, palpitations, syncope, unexplained tachycardia or hemodynamic instability. In hospitalized Vietnamese adults with predominantly non-severe dengue, electrocardiographic abnormalities and biochemical evidence of myocardial injury were documented, and dengue can range from clinically silent cardiac involvement to myocarditis. [129]C Consider serial cardiovascular assessment in symptomatic or high-risk patients. [129]C
Context and follow-up
A single examination may underestimate risk because clinical manifestations vary substantially between studies and outbreaks. A Peruvian systematic review documented marked variability in dengue manifestations across observational studies, while recent surveillance has identified shifts in serotype circulation, spatial risk and clinical phenotype. [104][177]C Reassess patients with persistent fever, new warning symptoms, bleeding, respiratory complaints, reduced urine output, neurologic symptoms or worsening fatigue. Post-acute symptoms, including persistent fatigue and depressive symptoms, may continue after the acute illness; prospective traveller follow-up studies evaluated symptoms through 18 months after dengue and other vector-borne infections. [123][126]
| Domain | Findings to seek | Evidence |
|---|---|---|
| Fever and timing | Onset, measured temperature, persistence, deterioration around defervescence | [26][130] |
| Exposure and differential | Residence/travel, mosquito exposure, malaria risk, co-infection risks | [41]D[110]C[124]C[125][134] |
| Plasma leakage and shock | Abdominal findings, ascites, pleural effusion, perfusion, blood pressure, urine output | [131] |
| Respiratory | Cough, lower-respiratory symptoms, chest distress, oxygen saturation | [45]D |
| Neurologic | Seizures, altered consciousness, focal deficits, weakness, sensory or sphincter changes | [122]C[131] |
| Cardiac | Chest pain, palpitations, syncope, dyspnoea, hemodynamic instability | [129]C |
Diagnosis and Workup
- ▸Use RT-PCR, NS1 antigen, and dengue IgM as complementary diagnostic methods; a negative result from one method does not necessarily exclude dengue [109][181][182].
- ▸Assess serial CBC results, hepatic involvement, bleeding, hemodynamics, and organ function because severe dengue reflects evolving vascular leakage and systemic disease [135][140][181].
- ▸Consider ultrasound as an adjunct for detecting plasma leakage, while recognizing that no single validated ultrasound threshold is established in the cited evidence [178].
- ▸Actively evaluate chikungunya, leptospirosis, malaria, melioidosis, scrub typhus, COVID-19, and bacterial infection when clinical features or epidemiology are compatible [137][139][145][158][179].
- ▸Serotype testing supports surveillance and outbreak characterization but does not replace bedside severity assessment [177][180].
- ▸Interpret dengue antibodies cautiously in previously exposed patients because secondary infection, cross-reactivity, and genotype-specific responses can affect results [107][109][144].
Diagnostic approach
Dengue should be considered in patients with an acute febrile illness in an endemic or outbreak setting, particularly when clinical and laboratory findings are nonspecific and other arboviral, bacterial, or viral infections are circulating concurrently [139][145][158][182]. Clinical assessment should document the duration of fever, hydration and hemodynamic status, bleeding manifestations, abdominal or neurologic symptoms, and evidence of hepatic or other organ involvement, because dengue ranges from uncomplicated febrile illness to vascular leakage, hemorrhage, shock, and organ failure [135][178][181]. Secondary infection, changing serotype circulation, and evolving population immunity can alter disease expression and may complicate interpretation of diagnostic tests [107][109][144]C[177]C.
Laboratory confirmation in the available studies has used direct detection of dengue viral RNA by RT-PCR, NS1 antigen detection, and dengue-specific IgM testing [109][180][181][182]. In the 2025 Bangladesh outbreak study, laboratory-confirmed dengue was defined as a positive NS1 antigen or dengue IgM test [181]. RT-PCR and NS1 are direct diagnostic methods, but their agreement was imperfect in a study of sequential outbreaks; notably, a comparison subset included 107 samples negative by both RT-PCR and NS1 despite investigation of suspected acute dengue [109]. Consequently, a negative result from one direct method should be interpreted with the clinical context and timing of specimen collection rather than treated as definitive exclusion of dengue [109].
Molecular testing can also identify the infecting serotype and support surveillance. A national Indian external-quality-assurance program evaluated pan-dengue molecular serotyping across virus research and diagnostic laboratories using coded dengue-positive and dengue-negative serum panels distributed in three rounds from December 2024 through February 2026 [180]. Serotype information is clinically and epidemiologically relevant because outbreaks may involve serotype replacement, geographic redistribution, and changing clinical phenotypes [177]C. However, serotype identification should not substitute for immediate clinical assessment of severity [135][177]C.
Initial laboratory workup and severity assessment
At presentation, obtain serial complete blood counts and assess trends rather than relying on a single value, because dengue-associated thrombocytopenia and vascular leakage may evolve during illness [135][142][181]. CBC-based diagnostic prediction has been studied using conventional parameters and automated-analyzer cell-population data; an externally validated logistic-regression approach was developed to predict RT-PCR-confirmed dengue in clinically suspected cases [182]. These models are adjuncts and do not replace virologic or serologic confirmation [182].
Evaluate hepatic and systemic organ involvement with routine biochemical testing. Liver involvement may progress to liver failure, and a retrospective study of hospitalized dengue patients used demographic and routine laboratory variables to identify parameters associated with liver failure and to develop a machine-learning model [140]. The available evidence supports early recognition and serial monitoring of hepatic injury, but the cited abstract does not establish a universal laboratory cutoff for liver failure [140]. Neurologic symptoms require targeted assessment; a systematic review identified dengue-associated spinal-cord involvement as uncommon but clinically important and evaluated neurologic manifestations, spinal imaging, treatment, and outcomes [143].
Investigate vascular leakage and evolving severe disease when clinically indicated. Ultrasound can detect plasma-leakage manifestations in viral hemorrhagic fevers, and a systematic review specifically assessed ultrasound findings and their ability to predict severe disease in dengue and related infections [178]. The available abstract supports ultrasound as an adjunct for detecting leakage but does not provide a single validated ultrasound threshold that should be used in isolation [178].
Differential diagnosis and coinfection
Dengue frequently overlaps clinically with chikungunya, and early symptoms may be difficult to distinguish without molecular testing [139]. A validated hospital-based machine-learning model used routine clinical signs and standard laboratory results to differentiate chikungunya from dengue where RT-PCR access is limited [139]. Chikungunya exposure may also be missed among patients initially hospitalized with suspected dengue: retrospective testing during Brazil’s 2024 outbreak detected chikungunya IgM in 16.6% of tested patients [145].
Leptospirosis, malaria, melioidosis, scrub typhus, and COVID-19 should remain in the differential diagnosis according to local epidemiology and exposure history [179][137]. Leptospirosis can mimic dengue and may occur as a coinfection; a systematic review in India evaluated its prevalence, geographic distribution, and clinical implications [179]. Dengue–SARS-CoV-2 coinfection has also been reported, with a systematic review describing overlapping clinical manifestations and laboratory findings from reports published between 2020 and 2025 [137]. In young febrile infants, bacterial and viral infections may be difficult to separate clinically; a Colombian cohort developed an internally validated machine-learning model using clinical and laboratory variables, supporting a broader infectious workup when dengue is possible but not established [158].
Interpretation and advanced testing
Serology requires contextual interpretation because acute-phase antibody profiles vary with prior exposure. In children with DENV-1 infection, acute-phase IgG, DENV-specific antibodies, NS1 antibodies, and neutralizing antibodies were studied alongside viremia and clinical manifestations during the first 7 days from symptom onset [144]C. Cross-reactive antibodies may complicate interpretation: pediatric samples showed neutralization and in-vitro antibody-dependent enhancement patterns differing by DENV-3 genotype, while orthoflavivirus cross-reactivity was also examined [107]. Emerging biomarkers such as NLRP3-inflammasome, autophagy, and cytokine measurements have been associated with severity in research cohorts, but they are not established routine diagnostic tests [150].
| Tool | Role | Important limitation |
|---|---|---|
| RT-PCR | Direct detection of dengue RNA; may support serotyping | Agreement with NS1 is imperfect, and some suspected cases are negative by both methods [109][180] |
| NS1 antigen | Direct detection used for laboratory confirmation | Sensitivity and agreement with RT-PCR vary across outbreaks and samples [109][181] |
| Dengue IgM | Laboratory confirmation in outbreak surveillance and clinical studies | Requires contextual interpretation when other infections or prior exposure are possible [137][181] |
| CBC and automated cell-population data | Supports diagnostic prediction and serial assessment of thrombocytopenia or evolving illness | Prediction models are adjunctive and do not replace confirmation [142][182] |
| Liver tests | Identify hepatic involvement and possible risk of liver failure | No universal cutoff is established by the cited study [140] |
| Ultrasound | Detects manifestations of plasma leakage and may assist severe-disease prediction | No single validated threshold is provided in the cited abstract [178] |
| Neurologic imaging | Investigates suspected spinal-cord involvement or other neurologic complications | Spinal-cord disease is uncommon and evidence is largely observational [143] |
Special Populations
- ▸Children and adolescents have substantial dengue burden globally, and pediatric fever may require molecular testing because dengue can overlap with bacterial infection, malaria, and other arboviral disease [70,124,158].
- ▸Prolonged fever defined as **>38.3°C beyond day 7** occurred in 11.06% of a Colombian pediatric cohort and was associated with severe dengue and immune dysregulation [130].
- ▸Pregnancy-associated dengue has been linked in published studies with maternal mortality, pregnancy loss, and preterm birth, but estimates are heterogeneous and evidence credibility varies [46,154].
- ▸Rare but serious complications include dengue-associated Guillain–Barré syndrome and hemophagocytic lymphohistiocytosis [153,183].
- ▸Dengue may be underdiagnosed in malaria-endemic and newly affected settings, including Mali and Gabon, making arboviral testing important in febrile patients [41,110].
Children and adolescents
Children and adolescents are a major dengue-risk population worldwide. A systematic review and meta-analysis of 158 studies found that incidence proportions were broadly similar across the Americas, Africa, and Asia, although estimates varied substantially by country and age group [70]. Global burden analyses also identified important age-, sex-, and geography-related differences in dengue incidence and disability-adjusted life-years, with South Asia and India showing substantial long-term disease burdens [81]D.
Clinical recognition may be difficult in children because dengue overlaps with other causes of acute fever. In a prospective cohort of children aged under 14 years in Nepal, molecular testing was used alongside routine diagnostics and NS1 antigen testing during a dengue outbreak to identify dengue and other infectious causes of fever [124]C. In Gabon, molecular testing of febrile children demonstrated circulation of multiple dengue serotypes and assessed dengue–malaria coinfection, highlighting the risk of attributing pediatric fever solely to malaria [41]D. Similarly, a study of acute undifferentiated fever in Mali evaluated dengue among patients with illness lasting less than 7 days, reflecting the potential for dengue to be under-recognized in malaria-endemic settings [110]C.
Recent pediatric studies emphasize markers of severity. In hospitalized children with dengue warning signs or severe dengue in Colombia, fever persisting at >38.3°C beyond illness day 7 occurred in 11.06% of patients; prolonged fever was associated with a higher proportion of severe dengue and immune dysregulation [130]. In South India, quantitative NS1 antigen and IgM/IgG antibody titers were evaluated in laboratory-confirmed patients aged 1 month to 18 years for associations with bleeding, third spacing, thrombocytopenia, hepatic or renal involvement, shock, and hospitalization duration; the study also assessed whether the IgM/IgG ratio could distinguish primary from secondary infection [152]. Prospective pediatric research has further evaluated hyperferritinemia as a marker associated with severe dengue, organ dysfunction, multiple-organ dysfunction, thrombocytopenia, and ventilatory support [159].
A six-year retrospective study in Puducherry included 632 hospitalized pediatric dengue patients and examined clinical and epidemiologic trends before and during the COVID-19 pandemic [84]D. Young infants require particular diagnostic caution: a 13-year Colombian cohort involving patients under 18 years developed and internally validated a machine-learning model to distinguish bacterial from viral infection using nine clinical and laboratory variables, because febrile infants in dengue-hyperendemic areas may have overlapping presentations [158].
Rare severe complications also occur in children. Dengue-associated hemophagocytic lymphohistiocytosis (DA-HLH) is an uncommon hyperinflammatory complication that can clinically resemble severe dengue and delay recognition; a Colombian pediatric cohort used HLH-2004 criteria and the HScore to characterize clinical findings, laboratory abnormalities, treatments, and outcomes [183]C.
Pregnancy
Pregnancy is a clinically important special population because dengue may affect both the pregnant individual and the fetus. A systematic review of 23 studies published from 2010 onward found that infection was most frequently acquired during the third trimester. Reported ranges among dengue-infected pregnant individuals included maternal mortality of 0–21.7%, pregnancy loss of 0–11.6%, and preterm birth of 4.3–37.5% [154]. Interpretation is limited by heterogeneity, incomplete quantitative comparisons with dengue-negative pregnant populations, and other methodological limitations [154].
An umbrella review of systematic reviews and meta-analyses concluded that maternal dengue infection may be associated with adverse pregnancy and fetal outcomes, but the credibility of the evidence varies according to precision, consistency, small-study effects, and review quality [46]. Accordingly, pregnancy should prompt careful maternal assessment, fetal and obstetric monitoring, and a low threshold for escalation when warning signs or organ dysfunction develop, while recognizing that the available evidence does not provide uniform estimates of risk [46][154].
Neurologic and hyperinflammatory complications
Dengue-associated Guillain–Barré syndrome (GBS) is an uncommon neurologic complication. A systematic review identified 36 publications describing 56 patients from Asia, Latin America, and other endemic regions; the mean age was 34.9 years. The review synthesized clinical characteristics, outcomes, and predictors of severity, supporting consideration of GBS when progressive weakness or other compatible neurologic findings follow dengue [153].
Populations affected by changing transmission and diagnostic context
Dengue risk is not confined to traditionally recognized endemic areas. In Mali, investigation of acute undifferentiated fever from 2016–2024 evaluated arboviral infections, particularly dengue, in settings where malaria may mask the diagnosis [110]C. In Gabon, dengue serotypes were detected among febrile children and were assessed alongside malaria coinfection [41]D. In Colombia, a prospective hospital cohort during the 2023–2024 epidemic enrolled patients of all ages with virologically confirmed dengue and evaluated factors associated with serious manifestations, defined using severe dengue or dengue with warning signs [86]D. In Espírito Santo, Brazil, the 2023–2024 epidemic involved co-circulation of DENV-1 and DENV-2; reported cases included warning signs, severe dengue, hospitalization, and deaths [155].
Antibody interpretation may be especially challenging in children exposed to changing serotype patterns. In Myanmar, pediatric samples collected in 2017–2019 were compared with archived 2004 samples to evaluate antibody responses to emerging and previously circulating DENV-3 genotypes, in-vitro antibody-dependent enhancement, and cross-reactivity with Zika and Japanese encephalitis viruses [107].
Prevention in affected communities
Community-level prevention remains relevant to all special populations. A cluster-randomized trial in Singapore evaluated repeated release of male Aedes aegypti mosquitoes infected with wAlbB Wolbachia; mating with wild-type females produces nonviable offspring through cytoplasmic incompatibility, potentially suppressing mosquito populations and reducing dengue risk [2]. In southern Brazil, a six-year population-based cohort evaluated Dengvaxia effectiveness after a campaign offered in 30 municipalities, with approximately 300,000 people vaccinated and about 60% of participants receiving at least one dose; probable dengue, laboratory-confirmed dengue, serotype, warning signs, and hospitalization were assessed [74].
| Population or context | Evidence-based concern | Supporting evidence |
|---|---|---|
| Children and adolescents | High burden; overlapping causes of fever; risk of severe disease and organ involvement | [70][124]C[130][152] |
| Young infants | Difficulty distinguishing bacterial from viral infection in dengue-endemic settings | [158] |
| Pregnancy | Possible maternal mortality, pregnancy loss, preterm birth, and fetal effects; estimates are heterogeneous | [46][154] |
| Neurologic presentations | Dengue-associated GBS can follow infection and may be severe | [153] |
| Hyperinflammatory presentations | DA-HLH may mimic severe dengue and delay recognition | [183]C |
| Malaria-endemic or emerging transmission areas | Dengue and malaria may be misclassified or coexist | [41]D[110]C |
Guidelines and Resources
- ▸Use WHO-style categories—dengue without warning signs, dengue with warning signs, and severe dengue—as an organizing framework, but reassess patients serially because individual signs and classifications have limited correlation with actual severity. [91][92]
- ▸NAAT is preferred for suspected dengue or Zika; IgM adds diagnostic value but is limited by cross-reactivity and uncertain timing. [87]
- ▸Evaluate warning signs, hydration, postural blood-pressure changes, hematocrit, platelet trends, and possible fluid accumulation during follow-up. [94][160][166]
- ▸Supportive care and early recognition of shock, plasma leakage, bleeding, and organ involvement remain the basis of management. [164][167]
- ▸Use product-specific vaccination guidance; updated Dengvaxia safety information requires evidence of previous dengue infection. [162]
Scope and use of dengue guidance
Dengue guidance should be used as a clinical, laboratory, public-health, and prevention framework rather than as a substitute for repeated bedside assessment. Dengue encompasses a spectrum from uncomplicated illness to plasma leakage, shock, severe bleeding, and organ involvement, and early clinical findings may not reliably predict subsequent severity. [164] The revised WHO approach classifies illness as dengue without warning signs, dengue with warning signs, or severe dengue, but comparative studies found poor correlation between many recorded signs and guideline-defined severity, with limited agreement between the 1997 and 2009 classifications. [91] Prospective multicountry work nevertheless supported an intervention-oriented classification linked to the degree of medical and nursing support required and evaluated potential warning signs across children and adults. [92]
Diagnosis and laboratory resources
For patients with a clinically compatible illness and risk of dengue or Zika infection, nucleic acid amplification testing (NAAT) is the preferred diagnostic method; immunoglobulin M (IgM) testing can identify additional infections but is affected by flavivirus cross-reactivity and may not establish the precise timing of infection. [87] This distinction is particularly important when differentiating dengue from Zika, including in pregnancy, where the timing and specificity of serologic results can have major implications. [87]
Fever remains a central feature of the revised WHO case framework, but non-febrile dengue occurs and can complicate recognition. [93] A large retrospective study used laboratory confirmation by enzyme-linked immunosorbent assay, NS1 detection, or PCR, illustrating the value of combining clinical assessment with virologic or antigen-based testing when classification is uncertain. [93] Pediatric evaluation may incorporate serology, abdominal ultrasonography, and chest radiography alongside clinical assessment and routine laboratory testing. [165]
Triage, warning signs, and progression risk
Patients require reassessment during the febrile phase and around clinical deterioration because predictors of progression to severe dengue vary with illness timing. A systematic review and meta-analysis specifically evaluated predictors detectable during the febrile phase, emphasizing the need for early risk stratification rather than reliance on a single late finding. [90] Warning-sign assessment should include abdominal pain, persistent vomiting, fluid accumulation, mucosal bleeding, lethargy or restlessness, liver enlargement, and rising hematocrit with falling platelet counts, while recognizing that individual signs may have imperfect diagnostic performance. [94] Postural hypotension has also been evaluated as a potentially useful marker of intravascular volume reduction and capillary leak. [166]
Hydration status is relevant to ambulatory triage: a prospective primary-care study in Réunion reported oral fluid intake and examined hydration in relation to WHO warning signs, supporting explicit assessment and counseling about oral hydration when clinically appropriate. [94] A proposed adult dengue score used routine laboratory parameters to predict pleural effusion and/or ascites, but it was developed in hospitalized adults and should be regarded as an adjunct rather than a replacement for clinical examination and imaging. [160]
Management and supportive-care resources
No antiviral treatment had been established in the reviewed clinical literature; supportive care and early recognition of deterioration remain central management principles. [164] Plasma leakage and shock require careful fluid management, with close observation for both inadequate resuscitation and fluid overload. Case-based evidence describes dengue shock syndrome with ascites or pleural effusions despite crystalloid treatment and questions whether the presence of third-space fluid should influence fluid selection. [95]C These reports are limited by their small number of cases and do not establish a definitive superiority of colloids over crystalloids. [95]C
Fatal dengue investigations from Puerto Rico emphasize early recognition and supportive management as determinants relevant to preventing death during outbreaks. [167]C Adherence to WHO-based protocols may also affect resource use: a Brazilian cost analysis examined hospitalization costs and blood-product use when recommended dengue management protocols were not followed. [163]
Surveillance and outbreak resources
Dengue surveillance should connect the entire pathway from mosquito exposure and suspected infection through testing, case notification, clinical outcome, and public-health reporting. The Asia-Pacific and Americas Dengue Prevention Boards described surveillance methods, stakeholders, and operational steps based on expert input and reports from 22 countries. [88] Surveillance systems should therefore be designed to support both individual case management and detection of changing transmission patterns, while acknowledging that surveillance quality depends on case definitions, laboratory access, reporting completeness, and coordination among clinical and public-health services. [88]
Vaccination and prevention resources
Vaccine recommendations must be product-specific, jurisdiction-specific, and aligned with current regulatory information. The CYD-TDV dengue vaccine, Dengvaxia, requires evidence of previous dengue infection in the updated safety framework described in the prescriber-risk-minimization literature. [162] A survey of 300 prescribers in Brazil and Thailand found that educational measures did not generally achieve the predefined performance standard, indicating that dissemination of safety information alone may not ensure appropriate vaccination practice. [162] General vaccine-calendar publications, such as the Argentine pediatric update, provide immunization-program context but should not be interpreted as dengue-vaccine eligibility guidance without product-specific evidence. [89]
Emerging evidence and limitations
Research resources include candidate biomarkers and severity predictors, but these findings are not yet substitutes for validated bedside algorithms. Elevated soluble HLA-G levels were associated with dengue severity in Vietnamese hospitalized patients classified using WHO categories. [96]D A later study examined complement factors, acute-phase reactants, soluble complement receptor 1, serology, viral load, and clinical severity across dengue groups, illustrating ongoing investigation into biological markers of disease progression. [56]D Observational studies in travelers, children, and endemic populations demonstrate that WHO-based classification can be applied across varied settings, but differences in age, geography, referral patterns, and case mix limit direct generalization. [98]D[165] Accordingly, local protocols should specify testing availability, follow-up intervals, referral criteria, fluid-management procedures, reporting requirements, and vaccine eligibility while remaining consistent with the evidence and limitations summarized above. [88][87][90][164]
| Domain | Practical resource focus | Evidence |
|---|---|---|
| Diagnosis | NAAT, IgM interpretation, and differential diagnosis with Zika | [87] |
| Classification | WHO categories plus repeated severity assessment | [91][92][90] |
| Triage | Warning signs, hydration, postural hypotension, and fluid accumulation | [94][160][166] |
| Management | Supportive care, cautious resuscitation, and protocol adherence | [95]C[163][164][167]C |
| Public health | Integrated surveillance from exposure through reporting | [88] |
| Vaccination | Product-specific eligibility and safety communication | [89][162] |
References
- [1]
Chhabra S, Chia PY, Leo YS et al.. “A systematic review of dengue controlled human infection studies: safety, viral kinetics and immunology.” PLoS neglected tropical diseases (2026). PMID: 41818269 ↗
L2aSR_OBSCited in: Etiology and Triggering Factors - [2]
Lim JT, Chong CS, Chang CC et al.. “Dengue Suppression by Male Wolbachia-Infected Mosquitoes.” The New England journal of medicine (2026). PMID: 41671481 ↗
L1bRCTCited in: Etiology and Triggering Factors, Special Populations - [3]
Kamal MM, Tsheten T, Haque R et al.. “Epidemiological Characteristics of Dengue Infection in Bangladesh: A Systematic Review.” International journal of environmental research and public health (2026). PMID: 41752317 ↗
L2aSR_OBSCited in: Etiology and Triggering Factors - [4]
Mandaric S, Friberg H, Gottardo R et al.. “Humoral and cellular responses to a tetravalent dengue vaccine (TAK-003) in adults from a dengue non-endemic region: An open-label phase 2 trial.” Vaccine (2026). PMID: 41722532 ↗
L2bTRIAL_NONRANDOMCited in: Etiology and Triggering Factors - [5]
Ma M, Ye P, Pan J et al.. “Research progress of dengue virus T cell epitope mediated cellular immunity in avoiding ADE.” Frontiers in immunology (2026). PMID: 41993171 ↗
L5REVIEW_NARRATIVECited in: Etiology and Triggering Factors - [6]
Zeng R, Wu T, Zheng K et al.. “Advances in anti-dengue virus properties of Traditional Chinese Medicines.” Frontiers in microbiology (2026). PMID: 41889646 ↗
L5REVIEW_NARRATIVECited in: Etiology and Triggering Factors - [7]
Klingelhöfer D, Braun M, Kramer IM et al.. “Characteristics, Motivation, and Challenges of Global Research on Dengue Vaccination.” Reviews in medical virology (2026). PMID: 41766108 ↗
L5REVIEW_NARRATIVECited in: Etiology and Triggering Factors - [8]
Parra-González M, Nájera-Maldonado L, Peralta-Cuevas E et al.. “Dengue-SARS-CoV-2 interactions: immune crosstalk, variant emergence, and clinical outcomes.” Frontiers in immunology (2026). PMID: 41727479 ↗
L5REVIEW_NARRATIVECited in: Etiology and Triggering Factors - [9]
Shoushtari M, Bakhshi H, Salehi-Vaziri M et al.. “Distribution of Aedes aegypti and Aedes albopictus, and the current situation of dengue fever and chikungunya in Iran and neighboring countries: a review study.” PLoS neglected tropical diseases (2026). PMID: 41671227 ↗
L5REVIEW_NARRATIVECited in: Etiology and Triggering Factors - [10]
Tiley K, Yakob L, O'Reilly K et al.. “Mathematical modelling of Wolbachia replacement in Aedes aegypti for dengue control: a scoping review.” Proceedings. Biological sciences (2026). PMID: 41667103 ↗
L5REVIEW_NARRATIVECited in: Etiology and Triggering Factors - [11]
Bononad Brugger M, Valero MA, Morales-Suárez-Varela M. “Autochthonous transmission of dengue in Europe, with special attention to the Spanish context.” Epidemiology and infection (2026). PMID: 41755671 ↗
L5REVIEW_NARRATIVECited in: Etiology and Triggering Factors - [12]
Cremades R, Sandoval-Pinto E, Ortega-Prieto AM et al.. “Epidemiological Characteristics of Dengue Disease in Mexico (2014-2025): A Descriptive Analysis of a Hyperendemic Country.” Pathogens (Basel, Switzerland) (2026). PMID: 41754441 ↗
L5REVIEW_NARRATIVECited in: Etiology and Triggering Factors - [13]
Nandakumar A, Mishra D, Shendre A et al.. “Genomic diversity analysis enables development of pan-Dengue Toehold RNA sensors.” PLoS neglected tropical diseases (2026). PMID: 41990017 ↗
L5OTHERCited in: Etiology and Triggering Factors - [14]
León TM, McCready J, Chutaro E et al.. “Outbreak of Dengue Virus Serotype 3, Republic of the Marshall Islands, 2019-2021.” Emerging infectious diseases (2026). PMID: 41986995 ↗
L5OTHERCited in: Etiology and Triggering Factors - [15]
de Barros ENC, de Almeida Roediger M, Jackson ML et al.. “Dengue Incidence, Seroprevalence, and Expansion Factors from Active Surveillance, Brazil, 2016-2021.” Emerging infectious diseases (2026). PMID: 41986958 ↗
L5OTHERCited in: Etiology and Triggering Factors - [16]
Singh J, Lazzarotto T, Merakou C et al.. “Autochthonous dengue outbreak in Northern Italy, September 2024: epidemiological, microbiological, entomological investigation and public health response.” Travel medicine and infectious disease (2026). PMID: 41985827 ↗
L5OTHERCited in: Etiology and Triggering Factors - [17]
Pal A, Priyadarsini S, Sabat J et al.. “Detection of dengue virus serotypes in Aedes larvae: a multi-location study from Bhubaneswar, India, suggestive of vertical transmission.” Virology journal (2026). PMID: 41965806 ↗
L5OTHERCited in: Etiology and Triggering Factors - [18]
Ke Y, Wei H, Luo C et al.. “Dengue transmission dynamics in China's border regions adjacent to Myanmar.” Infectious diseases of poverty (2026). PMID: 41947237 ↗
L5OTHERCited in: Etiology and Triggering Factors - [19]
Bahr LE, Rothman AL, Barrett ADT et al.. “Addressing the elephant in the room: Proceedings of the third annual Dengue Endgame Summit.” PLoS neglected tropical diseases (2026). PMID: 41920817 ↗
L5OTHERCited in: Etiology and Triggering Factors - [20]
Gajdov V, Prosic I, Kavran M et al.. “Alignment-Free Machine Learning Serotype Classification of the Dengue Virus.” Viruses (2026). PMID: 41902188 ↗
L5OTHERCited in: Etiology and Triggering Factors, Diagnosis and Workup - [21]
Jabbar AA, Shaji V, Anil A et al.. “Phosphoproteome-Entailed Kinase-Substrate Landscape of Human-DENV-2 Interaction.” International journal of molecular sciences (2026). PMID: 41898579 ↗
L5OTHERCited in: Etiology and Triggering Factors - [22]
Alagarasu K, Gurav YK, Pulinchani A et al.. “Association of Viraemic Phase Viral Load, Antibody Responses, and Immune Biomarkers With Severe Dengue.” Journal of medical virology (2026). PMID: 41891425 ↗
L5OTHERCited in: Etiology and Triggering Factors, Diagnosis and Workup - [23]
Balasubramani K, Hussain SSA, Sawant SA et al.. “Dengue transmission dynamics in an urban setting in western India.” PLoS neglected tropical diseases (2026). PMID: 41871106 ↗
L5OTHERCited in: Etiology and Triggering Factors - [24]
Weng SC, Lin YS, Tsao PN et al.. “Dual functions of the Aedes aegypti ecdysone receptor in dengue virus replication and reproduction control.” Parasites & vectors (2026). PMID: 41866575 ↗
L5OTHERCited in: Etiology and Triggering Factors - [25]
Matulis GA, Smith HP, Hall G et al.. “Characterization of arbovirus infections in patients within Haiti by screening discarded malaria rapid diagnostic test cassettes.” PLoS neglected tropical diseases (2026). PMID: 41860982 ↗
L5OTHERCited in: Etiology and Triggering Factors - [26]
Pfaar H, López-Medina E, Escudero I et al.. “Operational challenges and lessons learned from conducting febrile surveillance in a long-term randomized dengue vaccine trial in Latin America and Asia-Pacific.” Travel medicine and infectious disease (2025). PMID: 40120920 ↗
L1bRCTCited in: History and Physical Examination - [27]
Minh Nguyen N, Thi Hoai Tam D, Quang Chanh H et al.. “Safety and tolerability of metformin in overweight and obese patients with dengue: An open-label clinical trial (MeDO).” PLoS neglected tropical diseases (2025). PMID: 40591696 ↗
L2bTRIAL_NONRANDOMCited in: History and Physical Examination - [28]
Chitrapady S, Rajendran R, K H et al.. “Machine-learning-based artificial intelligence tools for the diagnosis of tropical fevers: a systematic review and meta-analysis protocol of diagnostic test accuracy.” BMJ open (2025). PMID: 40854843 ↗
L2aSR_OBSCited in: History and Physical Examination - [29]
Yosef DK, Ismail AS, Awil BS et al.. “Epidemiology of dengue fever in Somaliland: clinical features, and serological patterns from a retrospective study.” BMC infectious diseases (2025). PMID: 39910527 ↗
L2bCOHORTCited in: History and Physical Examination - [30]
Mercado-Hernandez R, Myers R, Bustos Carillo FA et al.. “Obesity Is Associated With Increased Pediatric Dengue Virus Infection and Disease: A 9-Year Cohort Study in Managua, Nicaragua.” Clinical infectious diseases : an official publication of the Infectious Diseases Society of America (2024). PMID: 39004909 ↗
L2bCOHORTCited in: History and Physical Examination - [31]
Shih HI, Wang YP, Chi CY et al.. “Risks of anxiety disorders, depressive disorders, and sleep disorders in patients with dengue fever: A nationwide, population-based cohort study.” PLoS neglected tropical diseases (2024). PMID: 38959212 ↗
L2bCOHORTCited in: History and Physical Examination - [32]
Blumrick C. “Severe Infections in Returning Travelers.” The Medical clinics of North America (2025). PMID: 40185556 ↗
L5REVIEW_NARRATIVECited in: History and Physical Examination - [33]
Rosca EC, Garg D, Perez-Lloret S et al.. “Movement Disorders after Dengue Virus Infection: A Scoping Review.” Movement disorders : official journal of the Movement Disorder Society (2025). PMID: 39921518 ↗
L5REVIEW_NARRATIVECited in: History and Physical Examination - [34]
Ferraz ÁAB, Vasconcelos GP, Henriques DF et al.. “Impact of Prior Dengue or Chikungunya Infection on Bariatric Surgery Outcomes: An Observational Prospective Study.” Surgical infections (2026). PMID: 40999855 ↗
L2bCOHORTCited in: History and Physical Examination - [35]
Bhat R, Gupta N, Ravindra P et al.. “Assessment of Bleeding in Acute Febrile Illness with Thrombocytopenia Using Thromboelastography and Conventional Coagulation Parameters in the Emergency Department (ABATE): A Prospective Cohort Study.” The American journal of tropical medicine and hygiene (2025). PMID: 39933188 ↗
L2bCOHORTCited in: History and Physical Examination - [36]
León-Figueroa DA, Garcia-Vasquez EA, Diaz-Torres M et al.. “Prevalence of dengue in febrile patients in Peru: A systematic review and meta-analysis.” PloS one (2025). PMID: 40526741 ↗
L2aSR_OBSCited in: History and Physical Examination - [37]
Reddy M, Curtin J. “Fever and Rash in a Traveler.” Clinical infectious diseases : an official publication of the Infectious Diseases Society of America (2025). PMID: 39908174 ↗
L4CASE_REPORTCited in: History and Physical Examination - [38]
Alanazi GK, Ahmed YA, Alobaisi Y. “Bridging Gaps in Dengue Management: A Review of Diagnostics, Transfusion Needs, and Public Health Challenges.” Vector borne and zoonotic diseases (Larchmont, N.Y.) (2026). PMID: 41757795 ↗
L5REVIEW_NARRATIVECited in: History and Physical Examination - [39]
Ulgheri FM, Bernardes BG, Lancellotti M. “Decoding Dengue: A Global Perspective, History, Role, and Challenges.” Pathogens (Basel, Switzerland) (2025). PMID: 41011854 ↗
L5REVIEW_NARRATIVECited in: History and Physical Examination - [40]
Baje ZE, Lawal N, Bello MB et al.. “Dengue fever diagnosis in resource-limited settings.” Epidemiology and infection (2025). PMID: 40842435 ↗
L5REVIEW_NARRATIVECited in: History and Physical Examination - [41]
Moutombi Ditombi BC, Fritz M, Kombila Koumavor CA et al.. “Molecular evidence of co-circulation of different dengue virus serotypes associated with malaria co-infection among febrile children in Libreville, Gabon.” International journal of infectious diseases : IJID : official publication of the International Society for Infectious Diseases (2026). PMID: 41722758 ↗
L5OTHERCited in: History and Physical Examination, Diagnosis and Workup, Special Populations - [42]
Zapata-de la Cruz M, Martínez-Vega RA, Guzmán-Priego CG et al.. “Evaluating Three Rapid Tests for Dengue in Febrile Patients in a Dengue-Endemic Area.” Tropical medicine & international health : TM & IH (2026). PMID: 41601210 ↗
L5OTHERCited in: History and Physical Examination, Diagnosis and Workup - [43]
Cruz-Altamirano E, Mayoral-Chávez MA, Ramírez-Palacios LR et al.. “Pilot proteomic analysis of immune dysregulation in dengue with prior SARS-CoV-2 infection.” Frontiers in immunology (2025). PMID: 41583452 ↗
L5OTHERCited in: History and Physical Examination, Diagnosis and Workup - [44]
Chitrapady S, Rajendran R, Haritha K et al.. “Development and evaluation of a diagnostic aiding tool for differentiating tropical fevers using artificial intelligence approach: a study protocol from tertiary care hospital in South India.” BMJ open (2026). PMID: 41490850 ↗
L5OTHERCited in: History and Physical Examination, Diagnosis and Workup - [45]
Zhang B, Guo F, Wang P et al.. “A paradigm shift in DENV-4 clinical presentation: A viewpoint on pulmonary inflammatory symptoms from the 2023 Lincang outbreak.” PLoS neglected tropical diseases (2025). PMID: 41202061 ↗
L5OTHERCited in: History and Physical Examination - [46]
Fan D, Lin D, Rao J et al.. “Adverse Pregnancy Outcomes and Prevalence Associated With Arboviral Infections (Zika, Dengue, and Chikungunya): An Umbrella Review of Systematic Reviews and Meta-Analyses.” Reviews in medical virology (2026). PMID: 41840925 ↗
L2aSR_OBSCited in: Diagnosis and Workup, Special Populations - [47]
Agboli E, Jöst H, Frangoulidis D et al.. “Dengue in deployed military personnel, 1905-2024: a systematic review of incidence, diagnostics and prevention.” Journal of travel medicine (2026). PMID: 41283862 ↗
L2aSR_OBSCited in: Diagnosis and Workup - [48]
Durbin AP, Van Wesenbeeck L, Pierce KK et al.. “Daily Mosnodenvir as Dengue Prophylaxis in a Controlled Human Infection Model.” The New England journal of medicine (2025). PMID: 41297006 ↗
L1bRCTCited in: Diagnosis and Workup - [49]
Campbell AKO, Omah I, Diouf AM et al.. “Characterisation of the First Complete Dengue Genome in Sierra Leone.” Viruses (2026). PMID: 41902206 ↗
L4CASE_REPORTCited in: Diagnosis and Workup - [50]
Busaidi SA, Naabi MA, Lawati HA et al.. “Dengue fever uncovers a late diagnosis of sickle cell disease- a case report.” BMC infectious diseases (2025). PMID: 41275084 ↗
L4CASE_REPORTCited in: Diagnosis and Workup - [51]
El Kabbani S, Saleh G. “Next-Generation Diagnostic Technologies for Dengue Virus Detection: Microfluidics, Biosensing, CRISPR, and AI Approaches.” Sensors (Basel, Switzerland) (2025). PMID: 41516578 ↗
L5REVIEW_NARRATIVECited in: Diagnosis and Workup - [52]
Chakraborty S, Kasirajan A, Sunil A et al.. “Interferon Inducible Guanylate Binding Protein 5 (GBP5) and Its Association With Oxidative Stress Markers in Regulating Dengue Severity: A Clinical and In Vitro Evaluation.” Journal of medical virology (2026). PMID: 41923484 ↗
L5OTHERCited in: Diagnosis and Workup - [53]
Martins CB, David MR, Couto-Lima D et al.. “Wolbachia wMel and wAlbB strains differentially impact the vector competence of Aedes aegypti with a Brazilian genetic background for DENV-1 virus.” Parasites & vectors (2026). PMID: 41782057 ↗
L5OTHERCited in: Diagnosis and Workup - [54]
Delaporte B, Champagne M, Ayouba A et al.. “Serological signals of past dengue exposure in general practice in southern mainland France.” Journal of infection and public health (2026). PMID: 41747456 ↗
L5OTHERCited in: Diagnosis and Workup - [55]
Hauner A, Aroni-Sierra J, Merino X et al.. “Assessing the diagnostic performance of clinical, serological and molecular approaches to improve dengue case detection in the Peruvian Amazon.” PLoS neglected tropical diseases (2026). PMID: 41662405 ↗
L5OTHERCited in: Diagnosis and Workup - [56]
Anshad AR, Saravanan S, Murugesan A et al.. “Aberrant systemic acute-phase complement responses in conjunction with soluble CR1 attribute to varying grades of dengue disease severity.” Frontiers in immunology (2025). PMID: 41624861 ↗
L5OTHERCited in: Diagnosis and Workup - [57]
Segura K, Martel F, Franco MA et al.. “Virus-like Particles and Spectral Flow Cytometry for Identification of Dengue Virus-Specific B Cells in Mice and Humans.” Viruses (2025). PMID: 41600823 ↗
L5OTHERCited in: Diagnosis and Workup - [58]
Zé-Zé L, Borges V, Gouveia BR et al.. “Detection of dengue virus serotype 2 in local Aedes aegypti populations, Madeira Island, Portugal, 2025.” Parasites & vectors (2026). PMID: 41593468 ↗
L5OTHERCited in: Diagnosis and Workup - [59]
Patil R, Kavathekar A, Prabhu M et al.. “Tracking the clinico-microbiological profile and molecular characterization of dengue cases during the monsoon-season in Belagavi, Karnataka.” PLoS neglected tropical diseases (2026). PMID: 41557724 ↗
L5OTHERCited in: Diagnosis and Workup - [60]
Pereira SH, Franco-Luiz APM, Nogueira CT et al.. “Clinical, Serological, and Molecular Profile of Dengue Patients With Warning Signs During the 2024 Outbreak in Belo Horizonte, Brazil.” Journal of medical virology (2026). PMID: 41536183 ↗
L5OTHERCited in: Diagnosis and Workup - [61]
Elenga N, Thomas Boizan N, Irakoze E et al.. “Does Hydroxyurea Reduce Hospital Admissions in Patients With Both Sickle Cell Disease and Dengue Fever?” Pediatric blood & cancer (2026). PMID: 41524649 ↗
L5OTHERCited in: Diagnosis and Workup - [62]
Olarte G, Salamanca-Leguizamón C, Serrano-Coll H. “Epidemiological Profile and Clinical Determinants of Dengue Severity in a Colombian Andean Municipality.” The Yale journal of biology and medicine (2025). PMID: 41477460 ↗
L5OTHERCited in: Diagnosis and Workup - [63]
Tan C, Xing S, Xie X et al.. “Development and Application of a Rapid Field Detection Technology for DENV-2 Based on the HUDSON Nucleic Acid Extraction-Free/RT-RAA/CRISPR-Cas12a System.” Viruses (2025). PMID: 41472250 ↗
L5OTHERCited in: Diagnosis and Workup - [64]
Otero LM, Medina J, Ruiz-Valcarcel J et al.. “Monitoring Dengue Virus in Aedes aegypti to Improve Dengue Surveillance and Control in Puerto Rico.” Viruses (2025). PMID: 41472210 ↗
L5OTHERCited in: Diagnosis and Workup - [65]
Joensuu R, Olander V, Masika M et al.. “Dengue virus serotype 4 in Aedes aegypti mosquitoes in Kenya.” PLoS neglected tropical diseases (2025). PMID: 41468381 ↗
L5OTHERCited in: Diagnosis and Workup - [66]
Niranjan R, Ganesh K, Sunil A et al.. “Elucidation of neutrophils-mediated effect of MMP-2 on lung epithelial cells; implications for acute respiratory distress syndrome and severe dengue pathogenesis.” Frontiers in cellular and infection microbiology (2025). PMID: 41459161 ↗
L5OTHERCited in: Diagnosis and Workup - [67]
Limthongkul J, Attanonchai S, Yodweerapong T et al.. “A novel potent autophagy inhibitor HM-013 limits production of infectious dengue virus particles.” Virology journal (2025). PMID: 41444907 ↗
L5OTHERCited in: Diagnosis and Workup - [68]
Das S, Begum F, Ghora S et al.. “Engineered dengue virus NS1 mRNA-lipid nanoparticle induces therapeutic IgG production that lacks autoantibody activity and neutralizes NS1 entry in liver cells.” Vaccine (2026). PMID: 41442864 ↗
L5OTHERCited in: Diagnosis and Workup - [69]
Liu LT, Chen PC, Lin PC et al.. “Defining the clinical utility of dengue RT-iiPCR: stratification by days post-onset and primary vs. secondary infection during the 2023 Taiwan outbreak.” Travel medicine and infectious disease (2026). PMID: 41386401 ↗
L5OTHERCited in: Diagnosis and Workup - [70]
Nunez C, Eslick GD, Teutsch S et al.. “Global epidemiology of dengue in paediatric and adolescent populations: a systematic review and meta-analysis.” Infectious diseases (London, England) (2026). PMID: 41201140 ↗
L2aSR_OBSCited in: Special Populations - [71]
Goicochea-Ríos EDS, Otiniano NM, Rojas-Infantas LDC et al.. “Dengue infection during pregnancy and the occurrence of pathological neonatal outcome: a systematic review and meta-analysis.” F1000Research (2024). PMID: 40792237 ↗
L2aSR_OBSCited in: Special Populations - [72]
Cardim LL, Teixeira MDG, Costa MDCN et al.. “Socioeconomic markers of dengue mortality in the 100 Million Brazilian Cohort (2007-2018): A nationwide registry-based cohort study.” PLoS neglected tropical diseases (2025). PMID: 41183110 ↗
L2bCOHORTCited in: Special Populations - [73]
Mukherjee I, Ferland N, Nguyen KT et al.. “Comparative analysis of placental transmission mechanisms for Dengue and Zika viruses: outcomes and future directions.” Frontiers in immunology (2026). PMID: 41869332 ↗
L5REVIEW_NARRATIVECited in: Special Populations - [74]
Luhm KR, Shimakura SE, Raboni SM et al.. “Dengue Vaccine Effectiveness: Results from a 6-Year Population-Based Cohort Study in Southern Brazil.” The American journal of tropical medicine and hygiene (2026). PMID: 41662753 ↗
L2bCOHORTCited in: Special Populations - [75]
Etoa Ndoko AC, Tran PL, Lafont M et al.. “Clinical and biological characteristics of dengue in pregnant women in Reunion Island: A nested case-control analysis in the EPIDENGUE cohort study.” European journal of obstetrics, gynecology, and reproductive biology (2026). PMID: 41483607 ↗
L2bCOHORTCited in: Special Populations - [76]
Mejia R, Zhan B, Uzcategui NL et al.. “Chagas and Vector-Borne Disease Exposures in an Indigenous Community in the Ecuadorian Amazon: A Retrospective Study.” The American journal of tropical medicine and hygiene (2025). PMID: 40774243 ↗
L2bCOHORTCited in: Special Populations - [77]
Nombera-Aznaran N, Guevara-Lazo D, Llontop-Silva V et al.. “Dengue Virus Infection in Pregnancy during the 2023 and 2024 Dengue Outbreaks in Peru: A Retrospective Review in a Tertiary Referral Center.” The American journal of tropical medicine and hygiene (2025). PMID: 40858121 ↗
L5REVIEW_NARRATIVECited in: Special Populations - [78]
Rajan Radha R, Rajeswari B, Varikkattu Rajendran P et al.. “Dengue Infection in Pediatric Patients With Malignancies: A Single-center Retrospective Study.” Journal of pediatric hematology/oncology (2026). PMID: 41467899 ↗
L2bCOHORTCited in: Special Populations - [79]
Govardhan C, Narayanaswamy B, Ragavaiah Naidu P et al.. “Concomitant Dengue fever and Kawasaki disease in an infant: case report and review of the literature.” Paediatrics and international child health (2025). PMID: 41020614 ↗
L4CASE_REPORTCited in: Special Populations - [80]
Batheja D, Samria D, Wimberly MC et al.. “Socioeconomic and household water management determinants of malaria and other vector-borne disease prevention in Urban Gujarat, India.” Malaria journal (2026). PMID: 41703587 ↗
L5OTHERCited in: Special Populations - [81]
Velayutham R, Kalra S, Yadav S et al.. “Trends in dengue incidence and disease burden in South Asia with special reference to India: Insights from the global burden of disease data, 1990-2021.” Journal of infection and public health (2026). PMID: 41666533 ↗
L5OTHERCited in: Special Populations - [82]
Camprubí-Ferrer D, Thayer MB, Madewell ZJ et al.. “Economic burden of dengue in Puerto Rico, 2010-2023.” Infectious diseases of poverty (2026). PMID: 41588438 ↗
L5OTHERCited in: Special Populations - [83]
de Barros Almeida RAM, Kurozawa LL, de Almeida GB et al.. “Adverse dengue outcomes in patients with chronic kidney disease: A population-based analysis of 5.8 million individuals from Brazil.” PLoS neglected tropical diseases (2026). PMID: 41557722 ↗
L5OTHERCited in: Special Populations - [84]
Rahul A, Vijayalaksmi G, Vijayakumar B et al.. “Epidemiological and clinical trends in pediatric dengue: A six-year retrospective hospital-based study on pre-vs pandemic patterns in Puducherry, India.” Journal of infection and public health (2026). PMID: 41483530 ↗
L5OTHERCited in: Special Populations - [85]
Mahendran R, Zhang L, Xu R et al.. “Wildfire smoke and dengue burden in Brazil: Evidence from a nationwide study.” Environmental pollution (Barking, Essex : 1987) (2026). PMID: 41360345 ↗
L5OTHERCited in: Special Populations - [86]
Torres-Hernández D, Grubaugh ND, Murillo-Ortiz MA et al.. “Epidemiology and severity risk factors of dengue virus infection during the 2023-2024 outbreak in Colombia.” PLoS neglected tropical diseases (2025). PMID: 41348908 ↗
L5OTHERCited in: Special Populations - [87]
Sharp TM, Fischer M, Muñoz-Jordán JL et al.. “Dengue and Zika Virus Diagnostic Testing for Patients with a Clinically Compatible Illness and Risk for Infection with Both Viruses.” MMWR. Recommendations and reports : Morbidity and mortality weekly report. Recommendations and reports (2019). PMID: 31194720 ↗
L1cGUIDELINECited in: Guidelines and Resources - [88]
Beatty ME, Stone A, Fitzsimons DW et al.. “Best practices in dengue surveillance: a report from the Asia-Pacific and Americas Dengue Prevention Boards.” PLoS neglected tropical diseases (2010). PMID: 21103381 ↗
L1cGUIDELINECited in: Guidelines and Resources - [89]
. “[Update on vaccines: 2018 recommendations].” Archivos argentinos de pediatria (2019). PMID: 31833342 ↗
L1cGUIDELINECited in: Guidelines and Resources - [90]
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.” The Lancet. Infectious diseases (2021). PMID: 33640077 ↗
L2aSR_OBSCited in: Guidelines and Resources - [91]
da Silva NS, Undurraga EA, Verro AT et al.. “Comparison between the traditional (1997) and revised (2009) WHO classifications of dengue disease: a retrospective study of 30 670 patients.” Tropical medicine & international health : TM & IH (2018). PMID: 30282115 ↗
L2bCOHORTCited in: Guidelines and Resources - [92]
Alexander N, Balmaseda A, Coelho IC et al.. “Multicentre prospective study on dengue classification in four South-east Asian and three Latin American countries.” Tropical medicine & international health : TM & IH (2011). PMID: 21624014 ↗
L2bCOHORTCited in: Guidelines and Resources - [93]
Tukasan C, Furlan NB, Estofolete CF et al.. “Evaluation of the importance of fever with respect to dengue prognosis according to the 2009 WHO classification: a retrospective study.” BMC infectious diseases (2017). PMID: 28052760 ↗
L2bCOHORTCited in: Guidelines and Resources - [94]
Besnard O, Maillard O, Franco JM et al.. “Hydration and clinical warning signs of dengue fever in primary care: An observational prospective study.” Infectious diseases now (2023). PMID: 37054972 ↗
L2bCOHORTCited in: Guidelines and Resources - [95]
Premaratna R, Liyanaarachchi E, Weerasinghe M et al.. “Should colloid boluses be prioritized over crystalloid boluses for the management of dengue shock syndrome in the presence of ascites and pleural effusions?” BMC infectious diseases (2011). PMID: 21356095 ↗
L4CASE_REPORTCited in: Guidelines and Resources - [96]
Anh DD, The NT, Song LH et al.. “Elevated Soluble HLA-G Levels Associate With Dengue Severity in Vietnamese Patients.” Journal of medical virology (2025). PMID: 40910405 ↗
L5OTHERCited in: Guidelines and Resources - [97]
Ng CF, Lum LC, Ismail NA et al.. “Clinicians' diagnostic practice of dengue infections.” Journal of clinical virology : the official publication of the Pan American Society for Clinical Virology (2007). PMID: 17928264 ↗
L5OTHERCited in: Guidelines and Resources - [98]
Tai AY, McGuinness SL, Robosa R et al.. “Management of dengue in Australian travellers: a retrospective multicentre analysis.” The Medical journal of Australia (2017). PMID: 28403751 ↗
L5OTHERCited in: Guidelines and Resources - [99]
Lovera D, Martinez de Cuellar C, Araya S et al.. “Clinical Characteristics and Risk Factors of Dengue Shock Syndrome in Children.” The Pediatric infectious disease journal (2016). PMID: 27455442 ↗
L5OTHERCited in: Guidelines and Resources - [100]
Shah C, Vijayaraghavan G, Kartha CC. “Spectrum of cardiac involvement in patients with dengue fever.” International journal of cardiology (2021). PMID: 32931859 ↗
L5OTHERCited in: Guidelines and Resources - [101]
Jaenisch T, Hendrickx K, Erpicum M et al.. “Development of standard clinical endpoints for use in dengue interventional trials: introduction and methodology.” BMC medical research methodology (2018). PMID: 30442099 ↗
L5OTHERCited in: Guidelines and Resources - [102]
Alexanderian D, Ramos F, Chatterjee S et al.. “Safety and Immunogenicity of the Live-Attenuated Quadrivalent Dengue Vaccine V181 Compared With Butantan-DV Among Healthy Adults in Brazil: A Randomized, Double-Blind, Phase 2 Trial.” Clinical infectious diseases : an official publication of the Infectious Diseases Society of America (2026). PMID: 42383822 ↗
L2bCited in: Etiology and Triggering Factors - [103]
Peng K, Huang X, Huang P et al.. “Dengue outbreaks in China during 2005-2023: a systematic analysis.” Frontiers in cellular and infection microbiology (2026). PMID: 42682518 ↗
L2aCited in: Etiology and Triggering Factors - [104]
León-Figueroa DA, Aguirre-Milachay E, Meléndez Morote DL et al.. “Prevalence and Variability of Clinical Manifestations of Dengue in Peru: A Systematic Review and Meta-Analysis of Observational Studies.” Viruses (2026). PMID: 42515584 ↗
L2aCited in: Etiology and Triggering Factors - [105]
Alissa M, Alghamdi A, Alghamdi SA et al.. “Global molecular and serological evidence of dengue and chikungunya infection: a systematic review and meta-analysis of 158,608 tested participants.” Reviews on environmental health (2026). PMID: 42493484 ↗
L2aCited in: Etiology and Triggering Factors - [106]
Farrag MA, Aljowaie RM, Aziz IM et al.. “Epidemiological and Evolutionary Dynamics of Dengue Virus in Saudi Arabia: Insights from Three Decades of Molecular and Serological Surveillance.” International journal of molecular sciences (2026). PMID: 42450282 ↗
L2aCited in: Etiology and Triggering Factors - [107]
Balingit JC, Nwe KM, Lin H et al.. “Antibody Responses in Pediatric Dengue Indicate Emergence and Co-Circulation of DENV-3 Genotypes I and III in Myanmar and Orthoflavivirus Cross-Reactivity.” Journal of medical virology (2026). PMID: 42504426 ↗
L2bCited in: Etiology and Triggering Factors - [108]
Wong JM, Acevedo PK, Whitehead S et al.. “Dengue vaccines: The role of a correlate of protection in evaluating vaccine safety and risk.” Vaccine (2026). PMID: 42486049 ↗
L2bCited in: Etiology and Triggering Factors - [109]
Espindola SL, Pereson MJ, Lema JM et al.. “Increasing Frequency of Secondary Dengue Infections in Sequential Outbreaks (2016-2024)-Clinical Impact and Diagnostic Challenges.” Viruses (2026). PMID: 42515637 ↗
L3bCited in: Etiology and Triggering Factors - [110]
Doumbia L, Thirion L, Klitting R et al.. “Study of patients with acute undifferentiated fever identifies dengue as a growing threat to public health in Mali.” PLoS neglected tropical diseases (2026). PMID: 42418522 ↗
L4Cited in: Etiology and Triggering Factors - [111]
Karyanti MR, Satari HI, Hadinegoro SR et al.. “Neutralizing dengue antibodies after 10 years of the chimeric yellow fever tetravalent dengue vaccine (CYD-TDV) and dengue antibody cross-reactivity with SARS-CoV-2 in Indonesia.” Acta tropica (2026). PMID: 42537921 ↗
L2bCited in: Etiology and Triggering Factors - [112]
Simmons OS, Vicco A, Martínez-Vega RA et al.. “Overall and serotype-specific dengue virus transmission intensity in Mexico, 2016-2023: A modelling study of case-notification data.” PLoS medicine (2026). PMID: 42691122 ↗
L4Cited in: Etiology and Triggering Factors - [113]
López O, Tirao E, Juarez X et al.. “Atypical manifestations of dengue in pediatric patients hospitalized during the 2023-2024 epidemic in Argentina: a multicenter registry.” European journal of pediatrics (2026). PMID: 42371151 ↗
L4Cited in: Etiology and Triggering Factors - [114]
Sorgho PA, Kafando AO, Ouedraogo RA et al.. “HLA-DRB1*03 and HLA-DRB1*04 alleles in patients infected with dengue virus in Burkina Faso.” Infection, genetics and evolution : journal of molecular epidemiology and evolutionary genetics in infectious diseases (2026). PMID: 42425382 ↗
L3bCited in: Etiology and Triggering Factors - [115]
Ghzwani AH, Alzubaidi MA, Al-Mekhlafi HM et al.. “Molecular and Serological Surveillance of Dengue Virus and Vector Dynamics in the Highlands of Southwestern Saudi Arabia.” Current microbiology (2026). PMID: 42509367 ↗
L3bCited in: Etiology and Triggering Factors - [116]
Xayavong D, Somoulay V, Khamphaphongphane B et al.. “Epidemiological, virological, and clinical characteristics of dengue in the Lao People's Democratic Republic, 2022-2023: a cross-sectional study.” Tropical medicine and health (2026). PMID: 42374554 ↗
L3bCited in: Etiology and Triggering Factors - [117]
Brambilla R, Rockwood N, Michel J et al.. “Dual readout RT-LAMP for rapid on-site dengue virus detection and serotyping.” Microbiology spectrum (2026). PMID: 42684918 ↗
L5Cited in: Etiology and Triggering Factors - [118]
Xu B, Xiong D, Wang J et al.. “Comprehensive conservation profiling enables a robust multiplex RT-qPCR assay for simultaneous pan-detection and serotype discrimination of dengue virus.” Microbiology spectrum (2026). PMID: 42684914 ↗
L5Cited in: Etiology and Triggering Factors - [119]
Ooi SH, Huang AT, Kaewhiran S et al.. “The spatial structure of dengue transmission in Kamphaeng Phet Thailand.” PLoS neglected tropical diseases (2026). PMID: 42672012 ↗
L5Cited in: Etiology and Triggering Factors - [120]
Hjelt V, Dronseck A, Schey AM et al.. “Clinical and Analytical Performance of the AP Biotech Discovery® Dengue Virus RT-PCR Detection Kit.” Viruses (2026). PMID: 42655731 ↗
L5Cited in: Etiology and Triggering Factors - [121]
Kim E, Baur AS, Lee JH. “Temporal Rewiring of Innate Immunity by Vector-Borne Viruses for Host-Directed Antiviral Therapy.” International journal of molecular sciences (2026). PMID: 42653296 ↗
L5Cited in: Etiology and Triggering Factors - [122]
Duarte N, Ruiz O, Refaey A. “Clinical characteristics and outcomes of dengue-associated transverse myelitis: A systematic review of case reports.” Neurological sciences : official journal of the Italian Neurological Society and of the Italian Society of Clinical Neurophysiology (2026). PMID: 42257899 ↗
L4Cited in: History and Physical Examination - [123]
Condé A, Maillard O, Rodrigo C et al.. “Post-Infectious Fatigue and Depression Following Dengue: A Systematic Review and Meta-Analysis of Associated Factors.” Reviews in medical virology (2026). PMID: 42160632 ↗
L2aCited in: History and Physical Examination - [124]
O'Reilly PJ, Gautam MC, Pokhrel B et al.. “Causes of Fever in a Cohort of Nepali Children and the Potential Impact of Molecular Testing During a Dengue Fever Outbreak.” The Pediatric infectious disease journal (2026). PMID: 41612562 ↗
L4Cited in: History and Physical Examination - [125]
Ogony J, Menya D, Mangeni J et al.. “Public health facility vulnerabilities, preparedness, and health outcomes for Plasmodium falciparum and dengue virus-infected children under 5 years with acute febrile illnesses in Western Kenya.” Frontiers in public health (2025). PMID: 40771229 ↗
L2bCited in: History and Physical Examination - [126]
Hamer DH, Loreau JM, Huits R et al.. “Frequency and persistence of post-acute symptoms after chikungunya, dengue, Zika and malaria in travellers: a prospective multi-centre study.” Journal of travel medicine (2026). PMID: 42149962 ↗
L3bCited in: History and Physical Examination - [127]
Bich DT, Hoan TT, Hung LX et al.. “Attenuated clinical presentation but severe laboratory evolution: a longitudinal analysis of dengue infection in older adults hospitalized in Northern Vietnam.” International journal of infectious diseases : IJID : official publication of the International Society for Infectious Diseases (2026). PMID: 41974269 ↗
L3bCited in: History and Physical Examination - [128]
Caronni S, Pieruzzi ME, Salari F et al.. “High rate of undiagnosed cases of fever among returning travelers from tropical areas tested for malaria: a single-center retrospective study.” Travel medicine and infectious disease (2026). PMID: 41812810 ↗
L3bCited in: History and Physical Examination - [129]
Nguyen HTT, Besson J, Bonell A et al.. “ECG changes and their utility in adult Vietnamese patients with non-severe dengue.” BMC infectious diseases (2026). PMID: 41749151 ↗
L4Cited in: History and Physical Examination - [130]
Segura K, Silva JM, Niño AP et al.. “Prolonged Fever in Pediatric Dengue is Associated With Clinical Severity and Immune Dysregulation.” The Pediatric infectious disease journal (2026). PMID: 41559858 ↗
L3bCited in: History and Physical Examination - [131]
Mendoza-Hernandez MA, Diaz-Martinez J, Hernández-Fuentes GA et al.. “Unexpected Predictors of Mortality During a DENV-3 Outbreak in Western Mexico: Seizures, Polyserositis, and Renal Dysfunction Without Severe Thrombocytopenia.” Viruses (2025). PMID: 40733567 ↗
L3bCited in: History and Physical Examination - [132]
Liang X, Dang S, Liang S et al.. “Safety of Low-Dose Ibuprofen in Non-Severe Dengue Patients for Managing Fever Is Consistent With Acetaminophen: A Retrospective Observational Study.” Journal of medical virology (2025). PMID: 40708402 ↗
L3bCited in: History and Physical Examination - [133]
Bhardwaj P, Kumar R, Behera SP et al.. “Epidemiology of acute undifferentiated febrile illness and acute encephalitis syndrome cases in Northern India: a prospective observational study.” Infectious diseases (London, England) (2025). PMID: 40317274 ↗
L3bCited in: History and Physical Examination - [134]
Sondén K, Satarvandi D, Hildenwall H et al.. “Fever in travelers returning from tropical and subtropical areas: a hospital-based study of factors affecting investigations and diagnoses in children and adults.” Travel medicine and infectious disease (2025). PMID: 40311664 ↗
L3bCited in: History and Physical Examination - [135]
Navarro Quiroz R, Escorcia Lindo K, Jaruffe Pinilla A et al.. “Mechanistic constraints in dengue severity: a systematic review with evidence stratification and agent-based evaluation of logical sufficiency.” Frontiers in immunology (2026). PMID: 42404909 ↗
L1aCited in: Diagnosis and Workup - [136]
Kulkarni PS, Potey AV, Gupta SK et al.. “Safety and Preliminary Efficacy of Dengue Monoclonal Antibody in Adult Patients: A Randomized Clinical Trial.” JAMA network open (2026). PMID: 42640641 ↗
L4Cited in: Diagnosis and Workup - [137]
Adnyanaschah R, Abdulah R, Oktora MP. “Clinical manifestations and laboratory findings in patients coinfected with dengue virus and SARS-CoV-2: a systematic review.” BMC infectious diseases (2026). PMID: 42286517 ↗
L2aCited in: Diagnosis and Workup - [138]
Le AT, Pham HT, Vu KD et al.. “Seroprevalence of dengue virus infection in people residing in Vietnam: A systematic review and meta-analysis.” Public health (2026). PMID: 42102766 ↗
L2aCited in: Diagnosis and Workup - [139]
Zhang L, Liu J, Mai JL et al.. “Development and validation of an interpretable machine learning model for early hospital-based differentiation of chikungunya and dengue fever using routine clinical data.” BMC infectious diseases (2026). PMID: 42337454 ↗
L2bCited in: Diagnosis and Workup - [140]
Zhao SY, Zhang YP, Zhou Z et al.. “Clinical and laboratory characteristics associated with liver failure in hospitalized dengue patients: insights from a non-endemic region.” BMC infectious diseases (2026). PMID: 42304250 ↗
L2bCited in: Diagnosis and Workup - [141]
Allyn J, Vidal C, Soupin-Coulin Q et al.. “Clinical phenotypes of severe dengue and their temporal evolution during a Reunion Island epidemic: a retrospective cohort study.” Travel medicine and infectious disease (2026). PMID: 42134483 ↗
L2bCited in: Diagnosis and Workup - [142]
Carretta LTA, Cosmo LD, Faria LC et al.. “Platelet Transfusion in Dengue-Associated Thrombocytopenia: A Systematic Review and Meta-Analysis.” Revista da Sociedade Brasileira de Medicina Tropical (2026). PMID: 42561330 ↗
L1aCited in: Diagnosis and Workup - [143]
Garg RK, Singh R, Paliwal VK et al.. “Clinical Spectrum, neuroimaging, treatment, and outcomes of dengue-associated spinal cord involvement.” Infectious diseases now (2026). PMID: 42309463 ↗
L2aCited in: Diagnosis and Workup - [144]
Bonnin FA, Bruno A, Bono MM et al.. “Acute-Phase Dengue Antibody Profiles in Pediatric Patients: Influence on Viremia and Disease Manifestations.” Viruses (2026). PMID: 42515593 ↗
L4Cited in: Diagnosis and Workup - [145]
Pereira SH, Reis JS, Franco-Luiz APM et al.. “Retrospective serology reveals chikungunya exposure among hospitalized dengue suspected cases in Minas Gerais, Brazil, 2024.” Journal of clinical virology : the official publication of the Pan American Society for Clinical Virology (2026). PMID: 42341540 ↗
L3bCited in: Diagnosis and Workup - [146]
Liu G, Wu X, Chang Y et al.. “A rapid multiplex platform for simultaneous detection of chikungunya virus, dengue virus, and dengue serotyping based on isothermal amplification and lateral flow dipsticks.” Infectious diseases of poverty (2026). PMID: 42104518 ↗
L3bCited in: Diagnosis and Workup - [147]
Lombardi F, Abatino A, Salvo PF et al.. “Dengue-specific T-cell memory following natural infection: a comparative analysis between people living with HIV and HIV-negative individuals.” Microbiology spectrum (2026). PMID: 42095669 ↗
L4Cited in: Diagnosis and Workup - [148]
Iqhrammullah M, Rampengan DDCH. “Arrhythmias in Dengue: Moving Upstream from Electrocardiographic Findings to Cardio-Hemodynamic Dysfunction. Comment on López-Delgado et al. Arrhythmias in Dengue: A Systematic Review and Meta-Analysis. Pathogens 2026, 15, 497.” Pathogens (Basel, Switzerland) (2026). PMID: 42515026 ↗
L2aCited in: Diagnosis and Workup - [149]
Sivasubramanian K, Bharath RR, Vajravelu LK et al.. “Assessment of IL-6 and IL-8 Levels and Other Bio Markers in Predicting Dengue Severity Across Serotypes.” Pathogens (Basel, Switzerland) (2026). PMID: 42075761 ↗
L2bCited in: Diagnosis and Workup - [150]
Thakur P, Ratho RK, Sharma N et al.. “Association of NLRP3 Inflammasome and Autophagy Pathways With Cytokine Storm and Disease Severity in Dengue Patients.” Journal of medical virology (2026). PMID: 42246437 ↗
L3bCited in: Diagnosis and Workup - [151]
Wu J, Huang D, Yi J et al.. “Dynamic landscape of peripheral blood lymphocyte subsets in dengue patients: a multimodal single-cell and flow cytometry analysis.” BMC infectious diseases (2026). PMID: 42106697 ↗
L3bCited in: Diagnosis and Workup - [152]
K H PP, Gerin P, Thiruvengadam V. “Predictive value of quantitative NS1 antigen, IgM and IgG antibody titres in assessing dengue severity in children.” European journal of pediatrics (2026). PMID: 42047860 ↗
L3bCited in: Diagnosis and Workup - [153]
Effiong MG, Yakubu AO, Lawal FI et al.. “Dengue virus infection and Guillain-Barré syndrome: a systematic review of clinical characteristics, outcomes, and predictors of severity.” BMC infectious diseases (2025). PMID: 41421983 ↗
L2aCited in: Special Populations - [154]
Rusu R, Durbin A, Clements I et al.. “Burden of Dengue in Pregnant Individuals: A Systematic Literature Review.” The American journal of tropical medicine and hygiene (2026). PMID: 42013833 ↗
L2aCited in: Special Populations - [155]
Ribeiro de Jesus N, Santos de Souza C, R Amorim M et al.. “Genomic and Epidemiological Characterization of DENV-1 and DENV-2 Co-Circulation During the 2023-2024 Dengue Epidemic in Espírito Santo, Brazil.” Journal of medical virology (2026). PMID: 42530293 ↗
L3bCited in: Special Populations - [156]
Jiang N, Liu W, Zhou H et al.. “Burden of Malaria and Dengue Across Global, Asian, and Chinese Populations Based on GBD 2021 Data: A Quantitative Assessment of Importation Risks to China.” Viruses (2026). PMID: 42357698 ↗
L3bCited in: Special Populations - [157]
Yang J, Mishra H, Ngai M et al.. “Secondary dengue virus infection is associated with endothelial activation and hypotension in an outpatient cohort from the Philippines.” Infectious diseases (London, England) (2025). PMID: 41175103 ↗
L3bCited in: Special Populations - [158]
Cortés-Guzmán LJ, Salgado DM, Narváez CF. “A 13-year cohort study using clinical machine learning to differentiate bacterial and viral infections in young infants in a dengue hyperendemic region.” Journal of tropical pediatrics (2026). PMID: 42483819 ↗
L3bCited in: Special Populations - [159]
Varghese L, Choudhary A, Jayachandran M et al.. “Hyperferritinemia in hospitalized children with dengue-a prospective observational study.” Journal of tropical pediatrics (2026). PMID: 42421325 ↗
L3bCited in: Special Populations - [160]
Suwarto S, Nainggolan L, Sinto R et al.. “Dengue score: a proposed diagnostic predictor for pleural effusion and/or ascites in adults with dengue infection.” BMC infectious diseases (2016). PMID: 27391122 ↗
L3bCited in: Guidelines and Resources - [161]
Srikiatkhachorn A, Gibbons RV, Green S et al.. “Dengue hemorrhagic fever: the sensitivity and specificity of the world health organization definition for identification of severe cases of dengue in Thailand, 1994-2005.” Clinical infectious diseases : an official publication of the Infectious Diseases Society of America (2010). PMID: 20205587 ↗
L3bCited in: Guidelines and Resources - [162]
Almas MF, Toussi M, Valero E et al.. “A cross-sectional survey to evaluate prescribers' knowledge and understanding of safety messages following Dengvaxia® product information update.” Pharmacoepidemiology and drug safety (2022). PMID: 35505623 ↗
L3bCited in: Guidelines and Resources - [163]
Vieira Machado AA, Estevan AO, Sales A et al.. “Direct costs of dengue hospitalization in Brazil: public and private health care systems and use of WHO guidelines.” PLoS neglected tropical diseases (2014). PMID: 25188295 ↗
L3bCited in: Guidelines and Resources - [164]
Wellekens K, Betrains A, De Munter P et al.. “Dengue: current state one year before WHO 2010-2020 goals.” Acta clinica Belgica (2020). PMID: 33090941 ↗
L2aCited in: Guidelines and Resources - [165]
Ramabhatta S, Palaniappan S, Hanumantharayappa N et al.. “The Clinical and Serological Profile of Pediatric Dengue.” Indian journal of pediatrics (2017). PMID: 28887788 ↗
L3bCited in: Guidelines and Resources - [166]
Mahabala C, Boloor A, Upadhya S et al.. “Postural fall in systolic blood pressure is a useful warning sign in dengue fever.” F1000Research (2023). PMID: 38178940 ↗
L3bCited in: Guidelines and Resources - [167]
Tomashek KM, Gregory CJ, Rivera Sánchez A et al.. “Dengue deaths in Puerto Rico: lessons learned from the 2007 epidemic.” PLoS neglected tropical diseases (2012). PMID: 22530072 ↗
L4Cited in: Guidelines and Resources - [168]
Belem LRW, Zongo A, Yao RK et al.. “Characterization of acute dengue immune status and serotype surveillance in three regions of Burkina Faso: a hospital-based cross-sectional study.” European journal of clinical microbiology & infectious diseases : official publication of the European Society of Clinical Microbiology (2026). PMID: 42850544 ↗
L3bCited in: Etiology and Triggering Factors - [169]
Bangoura ST, Soumah AK, Keita AK et al.. “Spatial distribution and factors associated with the seroprevalence of arboviruses in Guinea: a nationwide cross-sectional survey.” International journal of epidemiology (2026). PMID: 42777375 ↗
L3bCited in: Etiology and Triggering Factors - [170]
Nathaniel S, Arneaud W, Winter-Reece N et al.. “Laboratory-based trends in dengue and other arboviruses in the Caribbean: Analysis of surveillance data, 2018-2024.” Revista panamericana de salud publica = Pan American journal of public health (2026). PMID: 42852081 ↗
L3bCited in: Etiology and Triggering Factors - [171]
Salmona M, Schlupmann S, Mailhe M et al.. “Fatal Infection with Dengue Virus and Avian Orthoavulavirus 1 in Traveler Returning from Saudi Arabia to France, 2025.” Emerging infectious diseases (2026). PMID: 42726670 ↗
L4Cited in: Etiology and Triggering Factors - [172]
Taboada B, Zárate S, Díaz-González L et al.. “Regional and Temporal Dynamics of Dengue in Mexico (2020-2024): A Comprehensive Epidemiological Analysis.” Reviews in medical virology (2026). PMID: 42842946 ↗
L5Cited in: Etiology and Triggering Factors - [173]
Sberna G, Colavita F, Valli MB et al.. “Evaluation of the NovaplexTM Tropical Fever Virus Assay.” International journal of molecular sciences (2026). PMID: 42794825 ↗
L5Cited in: Etiology and Triggering Factors - [174]
García-Cordero J, Sánchez-Vargas LA, Luria-Pérez R et al.. “Expression and Immunogenic Application of Recombinant DENV-2 rprM Protein for the Non-Invasive Detection of Salivary IgA Antibodies.” International journal of molecular sciences (2026). PMID: 42794519 ↗
L5Cited in: Etiology and Triggering Factors - [175]
Khan S, Croda J. “El Niño 2026-27 and DENV-3 in Latin America: A Narrowing Window for Preparedness.” The Journal of infectious diseases (2026). PMID: 42766807 ↗
L5Cited in: Etiology and Triggering Factors - [176]
Obaga LB, Boondouylan T, Nuwong W et al.. “Resurgence and molecular epidemiology of dengue virus serotype 4 amid the COVID-19 pandemic in Thailand.” Journal of clinical virology : the official publication of the Pan American Society for Clinical Virology (2026). PMID: 42753459 ↗
L5Cited in: Etiology and Triggering Factors - [177]
Montilla Rodríguez LM, García-Balaguera C, Campo Palacio S et al.. “Early warning of serotype replacement, spatial risk redistribution, and shifting clinical phenotypes: Insights from the 2023-2025 dengue outbreak in Meta, Colombia.” PLoS neglected tropical diseases (2026). PMID: 42789565 ↗
L4Cited in: History and Physical Examination - [178]
Hodson DZ, Tambelli RA, Wahab MA et al.. “A systematic review of ultrasound to predict severe disease in patients with dengue and other viral infections associated with hemorrhagic fevers.” PLoS neglected tropical diseases (2026). PMID: 42752578 ↗
L2aCited in: Diagnosis and Workup - [179]
Joseph G, Kulavalli S, Bélard S et al.. “Leptospirosis and its co-infections in India: prevalence, geographic distribution, and clinical implications.” BMC infectious diseases (2026). PMID: 42363130 ↗
L2aCited in: Diagnosis and Workup - [180]
Ramalingam G, Krishnan S, Mukhopadhyay L et al.. “External quality assurance of molecular serotype detection of dengue virus RNA among virus research and diagnostic laboratories in India.” Frontiers in cellular and infection microbiology (2026). PMID: 42755533 ↗
L2bCited in: Diagnosis and Workup - [181]
Tabassum T, Zaman S, Khan MM et al.. “Clinical and epidemiological characteristics of the 2025 dengue outbreak in Bangladesh.” PLoS neglected tropical diseases (2026). PMID: 42647545 ↗
L3bCited in: Diagnosis and Workup - [182]
Hsu LC, Weng YC, Liu WC. “Development and External Validation of Logistic Regression Models Integrating Conventional Complete Blood Count and Cell Population Data for Predicting RT-PCR-Confirmed Dengue.” Journal of clinical laboratory analysis (2026). PMID: 42619337 ↗
L3bCited in: Diagnosis and Workup - [183]
De Zubiría Posada D, Cabrera Guarín V, Triviño Arias J et al.. “A Retrospective Analysis of Dengue-associated Hemophagocytic Lymphohistiocytosis in a Dengue-endemic Country.” The Pediatric infectious disease journal (2026). PMID: 41870541 ↗
L4Cited in: Special Populations