PDF: Unusual yet isolated oral manifestations of persistent thrombocytopenia

Platelets or thrombocytes are a critical component of vascular 'plugs' that form during hemostasis to limit blood loss secondary to vascular damage.

Consequently, disorders accompanied by insufficiencies of platelet number or platelet dysfunction may contribute to pathologic bleeding states. A platelet count of 150-450x103/ mm3 is considered normal . Thrombocytopenia is a hematologic disorder that is characterized by a markedly decreased number of circulating blood platelets.

A reduction in platelet number or function can occur through a variety of mechanisms, including autoimmune destruction, spleen sequestration, bone marrow infiltration by tumor cells, infection (e.g. dengue fever), and adverse drug reaction. Regardless of the cause, platelet disorders typically manifest with petechiae, purpura, and bleeding of the mucous membranes. 

Although these changes are detected most frequently on the skin; the oral cavity, the nasal and genital mucosa, as well as the renal and gastrointestinal systems, also may exhibit signs of bleeding4 . Spontaneous clinical hemorrhages are usually not observed until platelet counts fall below 30x103/mm3.

Gingival bleeding, either spontaneous or in response to minor trauma (i.e. tooth brushing, flossing), is often the first sign of thrombocytopenia. The oral mucosa, most notably the soft palate and buccal mucosa, may demonstrate petechiae and ecchymoses. Deep red to black hemorrhagic bullae may occur with very low platelet counts .

In case of dengue viral fever, mucocutaneous manifestations play significant role in its diagnosis. Though most of these manifestations are noted on ocular mucosa like conjunctiva, sclera, there have been reports of dengue fever presenting as small vesicles on soft palate, erythema and crusting of lips and tongue.

Here we report a case of thrombocytopenia associated with dengue fever, which showed only oral manifestations, thus highlighting the significance of recognizing the oral signs.

In this report, we describe a patient who presented isolated oral features of hemorrhagic bullae with bleeding, indicative of a bleeding disorder.