What is the likely diagnosis of a pearly papule at the soft palate in an adult patient with dengue fever and warning signs presenting with sore throat?

Pearly Papule at Soft Palate in Dengue Patient

Most Likely Diagnosis

The pearly papule at the soft palate in this adult dengue patient with sore throat most likely represents soft palate petechiae, a recognized manifestation of dengue hemorrhagic complications, though Group A Streptococcal (GAS) pharyngitis with characteristic palatal findings must also be considered as a concurrent or alternative diagnosis.

Primary Diagnostic Consideration: Dengue-Related Mucosal Manifestations

• Dengue infection commonly presents with mucocutaneous manifestations including hemorrhagic lesions and mucosal findings that provide important early diagnostic clues 1
• Bleeding diathesis is a statistically significant symptom in dengue patients presenting with acute febrile illness 2
• The patient has dengue with warning signs, which increases the likelihood of hemorrhagic phenomena including mucosal petechiae 3
• Sore throat occurs in approximately 3% of dengue cases, making concurrent pharyngeal involvement plausible 4

Alternative Diagnosis: Group A Streptococcal Pharyngitis

• Soft palate petechiae (described as "doughnut lesions") are a classic finding in GAS pharyngitis, along with beefy red swollen uvula and tonsillopharyngeal findings 5
• GAS pharyngitis presents with sudden-onset sore throat, pain on swallowing, fever, tonsillopharyngeal erythema with or without exudates, and anterior cervical lymphadenitis 5
• However, clinical findings alone cannot definitively diagnose GAS pharyngitis, and microbiological confirmation with throat culture or rapid antigen detection test (RADT) is required 5

Diagnostic Algorithm

Step 1: Assess for dengue hemorrhagic manifestations

• Examine for other bleeding phenomena (gingival bleeding, epistaxis, skin petechiae) 3
• Check platelet count - thrombocytopenia ≤100,000/mm³ suggests dengue hemorrhagic fever 3
• Monitor hematocrit for evidence of plasma leakage (>20% increase from baseline) 3

Step 2: Evaluate for concurrent bacterial infection

• Assess for GAS-specific features: tonsillar exudates, tender anterior cervical adenopathy, absence of viral symptoms (cough, rhinorrhea, conjunctivitis) 5, 6
• Perform throat culture or RADT if clinical suspicion for GAS is high, as dengue patients can develop secondary bacterial infections 5, 3

Step 3: Consider timing and clinical context

• If the patient is in the critical phase of dengue (days 3-7) with warning signs, hemorrhagic manifestations are more likely 3
• If fever persists and patient shows clinical deterioration, broaden management to cover potential secondary infections 3

Critical Management Points

• Avoid aspirin and NSAIDs completely due to increased bleeding risk in dengue 3
• Use acetaminophen for pain and fever relief 3
• If GAS is confirmed, treat with penicillin or amoxicillin for 10 days 6
• Monitor daily complete blood count to track platelet counts and hematocrit 3
• Watch for warning signs: persistent vomiting, abdominal pain, lethargy, mucosal bleeding, rising hematocrit with falling platelets 3

Common Pitfalls to Avoid

• Do not dismiss mucosal findings as purely infectious pharyngitis without considering dengue hemorrhagic complications in a patient with confirmed dengue and warning signs 3, 1
• Do not perform GAS testing when viral features (cough, rhinorrhea) strongly dominate the clinical picture 6
• Do not delay fluid resuscitation if signs of plasma leakage or shock develop while investigating the pharyngeal findings 3
• Avoid attributing all symptoms to dengue alone - secondary bacterial infections can occur and require specific treatment 3