This case report discusses the diagnostic and therapeutic challenges faced in the management of dengue hemorrhagic fever (DHF) in a patient with active lupus nephritis. The patient, a seventeen-year-old girl, experienced a renal flare of lupus and subsequently developed DHF with bleeding. Due to acute kidney injury, a restrictive fluid approach was adopted during the ascending limb, with blood transfusion as needed. Continuous monitoring for hemodynamic instability was conducted. During the descending limb, there was a transient increase in fluid input due to a rise in hematocrit, leading to nephrogenic pulmonary edema. Mechanical ventilation and continuous renal replacement therapy were employed to manage this complication. This case presented two diagnostic challenges: diagnosing dengue in a patient with lupus-related bicytopenia and identifying dengue leakage in a patient with nephrotic syndrome-related ascites. Therapeutic difficulties included determining the appropriate fluid quota for DHF in the presence of renal impairment and weighing the risks and benefits of steroids and anticoagulation in lupus nephritis with dengue. As management decisions in these cases are patient-specific, sharing individual experiences will aid in guiding future treatment approaches.

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