Endgames Case Review

Haemorrhagic bullae in the oral mucosa with gingival bleeding

BMJ 2017; 359 doi: https://doi.org/10.1136/bmj.j4476 (Published 26 October 2017) Cite this as: BMJ 2017;359:j4476
  1. César Rivera, professor of oral pathology and medicine1,
  2. Ítalo Torres, general dentist2,
  3. Wilfredo Alejandro González-Arriagada, professor of oral pathology and medicine3
  1. 1Department of Biomedical Sciences, Faculty of Health Sciences, University of Talca, Talca, Maule Region, Chile
  2. 2Department of Health, Municipality of Lolol, O’Higgins Region, Chile
  3. 3Oral Pathology and Diagnosis, Facultad de Odontología, Universidad de Valparaíso, Chile
  1. Correspondence to WA González-Arriagada wilfredo.gonzalez{at}uv.cl

A 56 year old woman presented with a 2 day history of multiple painless violet haemorrhagic lesions on her gums, tongue, and buccal mucosa (fig 1). This was associated with gingival bleeding, but there was no relevant medical history of comorbidity, medications, or local trauma. She was diagnosed with multiple haemorrhagic bullae. Blood tests done using fluorescence flow cytometry (Sysmex ​XS-1000i, Sysmex Corp. Japan) showed a platelet count of zero (reference range 150-400 ×109/L of blood). A manual platelet count was not performed. Coagulation, haemogram, and white blood cells tests were normal. A dermatological examination revealed further lesions on her chest and arms. She was treated with intravenous methylprednisolone (30 mg/kg/day) for seven days, and reached a count of 7 platelets ×109/L. Four days after the initial 7 day treatment, her platelets decreased rapidly to 3 ×109/L. The patient received a transfusion of 30×109/L platelets and prednisone (1 mg/kg/day). Five days after the transfusion, the woman left the hospital with a platelet count of 74 ×109/L.

Fig 1 Multiple violet haemorrhagic lesions on the gums, tongue, and buccal mucosa

Questions

  • 1. What is the most likely diagnosis?

  • 2. Which tests are necessary to diagnose this condition?

  • 3. How should this patient be managed?

Answers

1.What is the most likely diagnosis?

Short answer

Idiopathic thrombocytopenic purpura.

Discussion

Idiopathic thrombocytopenic purpura, also known as immune thrombocytopenic purpura, …

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