A 32-year-old woman from Mumbai presents on day 5 of fever with complaints of severe retroorbital pain, myalgia, and a blanching maculopapular rash over the trunk and extremities sparing palms and soles. Her platelet count is 85,000/μL, haemoglobin 14 g/dL, and haematocrit 38%. AST is 120 U/L and ALT is 95 U/L. She denies any warning signs. What is the most likely clinical classification of her dengue infection?

## Clinical Classification of Dengue The patient presents with classic dengue fever symptoms in the critical phase (day 5) but lacks any WHO-defined warning signs. ### Assessment of Warning Signs **Key Point:** WHO 2009 dengue classification defines warning signs as clinical or laboratory indicators that predict progression to severe dengue. These include: - Persistent vomiting - Severe abdominal pain - Bleeding (petechiae, purpura, epistaxis, haematemesis, melaena) - Lethargy or restlessness - Liver enlargement >2 cm - Rapid decrease in platelet count with rise in haematocrit ### Analysis of This Case | Feature | Finding | Significance | |---------|---------|---------------| | Fever duration | Day 5 | Critical phase | | Rash | Blanching maculopapular | Typical dengue | | Platelet count | 85,000/μL | Mild thrombocytopenia, but stable | | Haematocrit | 38% | No haemoconcentration | | Liver enzymes | Mildly elevated | Expected in dengue | | Bleeding manifestations | None | Absent | | Vomiting/abdominal pain | None | Absent | | Altered mental status | None | Absent | **High-Yield:** The absence of warning signs despite thrombocytopenia and hepatitis classifies this as **dengue without warning signs** — the mildest category that still requires monitoring but does not meet criteria for severe dengue. **Clinical Pearl:** Dengue without warning signs can be managed in outpatient settings with daily monitoring of platelets and haematocrit. The critical phase (days 3–7) is when warning signs typically emerge; if none appear by defervescence, prognosis is excellent. ### Why Not Severe Dengue? Severe dengue requires at least one of: - Severe plasma leakage (shock, respiratory distress) - Severe bleeding - Severe organ impairment (AST/ALT >1000 U/L, renal failure, encephalopathy) This patient's AST/ALT are only mildly elevated and there is no evidence of plasma leakage or organ failure.