Dengue remains one of the most common infectious diseases seen in Malaysian primary care. While many patients present during the febrile phase with mild symptoms, a subset will progress into the critical phase, where plasma leakage and haemodynamic instability can occur rapidly.
Recognising warning signs early is essential to prevent deterioration and guide timely referral.
A practical way to remember these red flags is the mnemonic ALL LOVES.
Why Warning Signs Matter
Warning signs reflect the onset of capillary leak, which increases the risk of shock, significant bleeding, and organ involvement. Detecting them early ensures appropriate monitoring, fluid management, and escalation of care.
The mnemonic ALL LOVES summarises the eight key clinical and laboratory features clinicians should watch for around days 3 to 7 of illness.
The “ALL LOVES” Mnemonic
A – Abdominal Pain
Severe or persistent abdominal pain is a key indicator of evolving plasma leakage or visceral involvement.
L – Liver Tender
Hepatic tenderness suggests dengue-related hepatitis or inflammation.
This often accompanies rising transaminases.
L – Low Platelets + High Haematocrit
A falling platelet count combined with a rising haematocrit strongly indicates plasma leakage.
This is one of the most reliable parameters in dengue monitoring.
L – Lethargy or Restlessness
Changes in mental or physical activity, including sudden lethargy or agitation, point to worsening perfusion.
O – cOnfusion
Any alteration in mental status — disorientation, slowed responses, or reduced awareness — signifies severe dengue and requires immediate escalation.
V – Vomiting or Diarrhoea
Persistent vomiting and diarrhoea worsen dehydration and may accelerate haemodynamic compromise.
E – Effusion (Pleural, Pericardial, or Ascites)
Fluid accumulation detected clinically or via POCUS reflects established plasma leakage.
S – Spontaneous Bleeding
Epistaxis, gum bleeding, purpura, or any bleeding without trauma suggests coagulopathy and marks severe disease.
When to Refer
Immediate referral to hospital is recommended when the patient has:
- Any warning sign listed above
- Inability to tolerate oral intake
- Rapidly rising haematocrit or clinical signs of dehydration
- Pregnancy, significant comorbidities, elderly patients
- Poor social support or inability to return for close monitoring
Conclusion
The ALL LOVES mnemonic provides clinicians with a quick, reliable method to recognise dengue warning signs during the critical phase. Early identification directly improves outcomes and prevents avoidable complications.
Feel free to share this with colleagues and locum groups — awareness saves lives.
SetelDoc — for Busy Doctors
Source: Dengue CPG Malaysia
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