Every monsoon our outpatient and emergency departments fill with fever. Most of these illnesses look similar in the first two days, and the distinctions become clear only as they evolve.
The important skill for patients is not diagnosing themselves, it is recognising when a fever has become dangerous.
The Distinguishing Features
Each of these illnesses has a characteristic pattern, though overlap is common.
Dengue: sudden high fever, severe headache typically behind the eyes, intense muscle and bone pain, nausea, and a rash appearing around day three to five. Platelet count falls.
Chikungunya: fever with severe joint pain, often in the hands, wrists, ankles and feet, frequently symmetrical and sometimes with swelling. The joint pain is the dominant feature and can persist for months.
Malaria: fever with distinct chills and rigors, often cyclical, with sweating as the fever breaks. Anaemia and an enlarged spleen may develop.
Typhoid: fever rising in a stepwise pattern over days rather than spiking, with abdominal discomfort, headache and often constipation early on.
Bone and eye pain suggests dengue. Severe joint pain suggests chikungunya. Rigors suggest malaria. But these are guides, not diagnoses.
Dengue Warning Signs
This is the most important section. Dengue becomes dangerous not at the peak of fever but as the fever falls, typically days four to six, when plasma leaks from blood vessels.
- Severe abdominal pain
- Persistent vomiting
- Bleeding from gums or nose, or bleeding under the skin
- Black tarry stools or blood in vomit
- Lethargy or restlessness
- Cold clammy skin
- Reduced urine output
- Rapid breathing
- A sudden drop in temperature with the patient looking worse rather than better
That last point is critical and counterintuitive. Patients and families are relieved when the fever settles, precisely when the critical phase begins. Anyone with dengue should be watched most carefully during defervescence.
Any of these signs requires immediate hospital assessment through our emergency service.
The Platelet Count Is Misunderstood
Families frequently focus entirely on the platelet number, checking it daily and panicking at each fall. The number matters less than most people believe.
Platelets fall in dengue as part of the illness and recover as it resolves. A falling count alone, in a patient who is drinking, passing urine and has no warning signs, is expected.
What matters more is haematocrit, which rises when plasma leaks from vessels, and the clinical state of the patient. A rising haematocrit with a falling platelet count indicates significant leakage.
Platelet transfusion is not given based on a number alone in dengue. It is reserved for active significant bleeding or very low counts with specific risk factors. Requesting transfusion because a number looks alarming is not helpful and carries its own risks.
Fluid Management Is the Treatment
There is no antiviral for dengue or chikungunya. Treatment is supportive, and fluid balance is the central element.
- Drink frequently: ORS, coconut water, buttermilk, soups and plain water
- Aim for pale urine passed regularly, which is the practical measure of adequacy
- Paracetamol for fever and pain, at appropriate doses
- Rest, since exertion during recovery prolongs fatigue
- Monitor for warning signs daily, particularly as the fever settles
Intravenous fluids are needed for those who cannot drink, who are vomiting persistently, or who show signs of leakage. That decision requires assessment rather than a fixed rule.
Medicines to Avoid
This matters more in dengue than in most illnesses.
Avoid ibuprofen, aspirin and other anti inflammatory painkillers in suspected dengue. They increase bleeding risk and can irritate the stomach lining at exactly the wrong time. Use paracetamol only.
This is a common error, since anti inflammatories are effective for the severe body aches and patients take them for relief.
Also avoid steroids unless specifically prescribed, and avoid intramuscular injections during the critical phase because of bleeding risk. Be cautious with herbal remedies, some of which affect platelet function or liver enzymes.
Papaya Leaf and Other Remedies
Papaya leaf extract is widely used in India for dengue and deserves a direct answer.
Some small studies suggest it may raise platelet counts modestly. The evidence is limited, and crucially, raising the platelet count is not the same as improving the outcome. Deaths in dengue result from plasma leakage and shock, not from low platelets alone.
It is unlikely to be harmful in reasonable amounts, and it is not a substitute for fluid management and monitoring. The danger is when families rely on it and delay bringing a deteriorating patient to hospital.
Tell your doctor about anything you are taking, including traditional preparations.
Chikungunya's Long Tail
The acute illness of chikungunya settles within a week or two. The joint pain frequently does not.
A substantial proportion of patients have persistent joint pain and stiffness for months, and some for over a year. This is genuinely disabling and is often dismissed once the fever has gone.
Management includes anti inflammatory painkillers, which are safe once dengue has been excluded, gentle exercise and physiotherapy, and assessment by rheumatology where symptoms persist beyond three months, since a small number develop an inflammatory arthritis requiring specific treatment.
Do not stop moving the joints. Immobility worsens stiffness considerably.
Prevention Around the Home
The dengue mosquito breeds in clean stagnant water and bites during the day, which changes the prevention approach.
- Empty and scrub water containers weekly, including coolers, flower pot trays, pet bowls and buckets
- Cover overhead and ground water tanks properly
- Remove discarded tyres, coconut shells and containers from the surroundings
- Clear roof gutters and terrace drains before and during the monsoon
- Use repellent during daytime hours, particularly early morning and late afternoon
- Wear long sleeves and use screens on windows
- Use bed nets for infants sleeping during the day
Weekly emptying matters because the mosquito completes its cycle from egg to adult in about a week. Emptying containers every week breaks that cycle, and it is more effective than fogging.
In monsoon fever, the key is not identifying the virus yourself but watching for deterioration. Drink steadily, use paracetamol only, and go to hospital immediately for abdominal pain, persistent vomiting, bleeding, drowsiness or reduced urine, particularly when the fever starts to settle.
Our general medicine department at T. Nagar assesses and manages fever, with inpatient care available for those needing monitoring.
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