Unifying Concepts

Diagnostic Criteria for Dengue Hemorrhagic Fever (DHS) and Dengue Shock Syndrome (DSS)

Dengue hemorrhagic fever is an immunopathologic disease; dengue virus–antibody immune complexes trigger release of vasoactive mediators by macrophages. The mediators increase vascular permeability, causing vascular leakage, hemorrhagic manifestations, hemoconcentration, and serous effusions, which can lead to circulatory collapse (ie, dengue shock syndrome).

Diagnostic Criteria for Dengue Hemorrhagic Fever (DHS) and Dengue Shock Syndrome (DSS)

Dengue Hemorrhagic Fever
Presence of all of the following:
Fever Acute onset of 2-7 days
Haemorrhagic manifestations Evidenced by positive tourniquet test, petechiae, ecchymoses or purpura, or bleeding from mucosa, gastrointestinal tract, injection sites, or other locations.
Thrombocytopenia Platelet count of ≤100 000 cells/mm3
Dengue Shock Syndrome (DSS)
Criteria for DHS (As above) and signs of shock Tachycardia, cool extremities, delayed capillary refill, weak pulse, lethargy or restlessness (a sign of reduced brain perfusion).
Pulse pressure ≤20 mmHg with increased diastolic pressure, e.g. 100/80 mmHg.
Hypotension by age, defined as systolic pressure <80 mmHg for those aged <5 years or 80 to 90 mmHg for older children and adults.

The first two clinical criteria, plus thrombocytopenia and haemoconcentration or a rising haematocrit, are sufficient to establish a clinical diagnosis of DHF. The presence of liver enlargement in addition to the first two clinical criteria is suggestive of DHF before the onset of plasma leakage. In cases with shock, a high haematocrit and marked thrombocytopenia support the diagnosis of DSS. A low ESR (<10 mm/first hour) during shock differentiates DSS from septic shock.



  1. Paz-Bailey G, Adams LE, Deen J, Anderson KB, Katzelnick LC. Dengue. Lancet. 2024 Jan 24:S0140-6736(23)02576-X. [Medline]
  2. Tejo AM, Hamasaki DT, Menezes LM, Ho YL. Severe dengue in the intensive care unit. J Intensive Med. 2023 Sep 28;4(1):16-33. [Medline]
  3. Singh RK, Tiwari A, Satone PD, Priya T, Meshram RJ. Updates in the Management of Dengue Shock Syndrome: A Comprehensive Review. Cureus. 2023 Oct 9;15(10):e46713. [Medline]
  4. Dengue: Guidelines for Diagnosis, Treatment, Prevention and Control: New Edition. Geneva: World Health Organization; 2009. [Medline]


Created Jan 24, 2024.

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