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• Fever typically lasts 2–7 days and can be biphasic.

• Other signs and symptoms may include severe headache; retro-orbital eye pain; muscle, joint, and bone pain; macular or maculopapular rash; and minor hemorrhagic manifestations including petechia, ecchymosis, purpura, epistaxis, bleeding gums, hematuria, or a positive tourniquet test result.

• Some patients have infected oropharynx and facial erythema in the first 24–48 hours after onset.

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• The critical phase of dengue begins at defervescence and typically lasts 24–48 hours.

• Most patients clinically improve during this phase, but those with substantial plasma leakage can, within a few hours, develop severe dengue as a result of a marked increase in vascular permeability.

• Initially, physiologic compensatory mechanisms maintain adequate circulation, which narrows pulse pressure as diastolic blood pressure increases.

• Patients with severe plasma leakage may have pleural effusions, ascites, hypoproteinemia, or hemoconcentration.

• Patients may appear to be well despite early signs of shock. However, once hypotension develops, systolic blood pressure rapidly declines, and irreversible shock and death may ensue despite resuscitation.

• Patients can also develop severe hemorrhagic manifestations, including hematemesis, bloody stool, or menorrhagia, especially if they have been in prolonged shock. Uncommon manifestations include hepatitis, myocarditis, pancreatitis, and encephalitis.

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• As plasma leakage subsides, the patient enters the convalescent phase and begins to reabsorb extravasated intravenous fluids and pleural and abdominal effusions.

• As a patient’s well-being improves, hemodynamic status stabilizes (although he or she may manifest bradycardia), and diuresis ensues. The patient’s hematocrit stabilizes or may fall because of the dilutional effect of the reabsorbed fluid, and the white cell count usually starts to rise, followed by a recovery of platelet count.

• The convalescent-phase rash may desquamate and be pruritic.

Laboratory findings commonly include leukopenia, thrombocytopenia, hyponatremia, elevated aspartate aminotransferase and alanine aminotransferase, and a normal erythrocyte sedimentation rate.