Dengue illness moves through three phases: the febrile phase, the critical phase, and the recovery phase. The transition into the critical phase typically occurs around day 3–7, most often as the fever begins to subside. In this case, the child is on day 5 and her fever has just resolved, which places her squarely in the window when plasma leakage is most likely to occur.
The combination of restlessness, cold extremities, delayed capillary refill, and a narrowed pulse pressure indicates compensated shock even when the systolic blood pressure remains within normal limits. Her blood pressure of 100/90 mmHg yields a pulse pressure of only 10 mmHg, which is a classic early sign of reduced effective circulating volume from plasma leakage.
Under the 2009 WHO classification, severe dengue is defined by one or more of the following: severe plasma leakage leading to shock or fluid accumulation with respiratory distress, severe bleeding, or severe organ involvement. The child’s presentation meets the criterion for shock from plasma leakage. Although she is still in the compensated stage, shock is already present.
Watch out! A normal systolic blood pressure does not rule out shock. In children, compensatory mechanisms such as tachycardia and increased systemic vascular resistance can maintain systolic pressure until late in the course. The more sensitive indicators are pulse pressure, capillary refill time, skin temperature, and mental status.
The case report by Santyadewi and colleagues describes a similar scenario in an early adolescent with compensated dengue shock syndrome (DSS), emphasizing that clinical recognition of compensated shock is critical because deterioration can be rapid once decompensation begins [2]. The retrospective study by Pratiwi and colleagues also distinguishes compensated from decompensated shock in children, reinforcing that compensated shock is still classified as severe dengue and requires immediate intervention [4].
Persistent vomiting and slight gum bleeding are important but are classified as warning signs, not as criteria for severe dengue by themselves. The presence of warning signs would place the child in the category of dengue with warning signs if shock were absent. However, once shock is identified, the classification escalates to severe dengue regardless of how mild the bleeding appears.
Key point! Warning signs alert the clinician to monitor closely, but the presence of shock—even compensated—immediately moves the case into the severe dengue category and mandates emergency referral and intravenous fluid resuscitation.
| Category | Key features | This case |
|---|---|---|
| Dengue without warning signs | Fever plus two of: nausea, rash, aches, leukopenia, positive tourniquet test; no warning signs | No—vomiting and bleeding are warning signs |
| Dengue with warning signs | Abdominal pain, persistent vomiting, mucosal bleeding, lethargy, fluid accumulation, hepatomegaly, rising Hct with falling platelets | Present, but shock supersedes this category |
| Severe dengue | Shock from plasma leakage, severe bleeding, or severe organ involvement | Yes—compensated shock from plasma leakage |
The systematic review by Horstick and colleagues notes that the 2009 WHO classification has higher sensitivity for detecting severe dengue compared with the 1997 classification, which supports using the 2009 framework to avoid missing cases like this one where shock is present but the systolic pressure has not yet fallen .
During the critical phase, increased vascular permeability allows plasma to leak into the extravascular compartment. This reduces intravascular volume and leads to haemoconcentration. The body initially compensates by increasing heart rate and peripheral vasoconstriction, which is why the hands feel cold and capillary refill is prolonged at 4 seconds . As leakage continues, the pulse pressure narrows because diastolic pressure rises from vasoconstriction while systolic pressure begins to fall from reduced stroke volume.
A pulse pressure of 20 mmHg or less in a child, together with signs of poor perfusion, is a strong indicator of compensated shock and warrants immediate fluid resuscitation. In this child, the pulse pressure of 10 mmHg is well below that threshold.
The nurse at the Barangay Health Station should recognize this as a medical emergency. The correct action is to classify the child as having severe dengue with compensated shock and arrange immediate transfer to a facility capable of administering intravenous fluids and monitoring for decompensation. Delaying referral while waiting for hypotension to develop risks progression to profound shock, which carries a much higher mortality.
The critical phase begins around defervescence (day 3–7), when plasma leakage peaks. A normal systolic BP does not exclude shock—look for narrowed pulse pressure (≤20 mmHg), delayed capillary refill (> 2 seconds), cold extremities, and restlessness.
A BP of 100/90 mmHg gives a pulse pressure of only 10 mmHg—a classic early sign of compensated shock from plasma leakage. This meets the WHO criterion for severe dengue and requires emergency referral for IV fluids.
Do not wait for hypotension. Children compensate until late; pulse pressure, capillary refill, and mental status are more sensitive than systolic BP alone. Slight gum bleeding and vomiting are only warning signs, not criteria for severe dengue.
학습 참고용입니다. 실제 임상은 최신 지침과 소속 기관 프로토콜을 따르세요.