Hemorrhagic Bullous Lesions in the Oral Cavity

A 55-year-old female presented with an asymptomatic, blood-filled blister inside the oral cavity for last 2 days. There was no history of trauma, oral/dental surgery, and intake of hot and crispy foods. On examination, a single, well-defined, nontender hemorrhagic bulla of size 2 cm in diameter was observed over the lateral surface of the tongue (►Fig. 1). Bulla ruptured spontaneously and healed within 5 to 6 days without any scarring. Rest of the mucocutaneous examination was normal. Here, oral cavity and teeth were normal and healthy. She was a known case of hypertension, but not taking regular medication. Her blood pressure was 170/120 mm of Hg at the time of visit. Complete blood counts and hepatic and renal function tests were normal. Her prothrombin time (PT/international normalized ratio) and activated partial thromboplastin time (aPTT) were within normal limits. Her fasting blood sugar level was 118 mg/dL and HbA1C was 6.2%.

Close

Fig. 1

Single, well-defined hemorrhagic bulla of size 2 cm in diameter over the left side of lateral surface of the tongue.

Export to PPT

On the basis of classical clinical morphology and investigations, we reached the diagnosis of angina bullosa hemorrhagica (ABH).

ABH is characterized by the sudden and spontaneous appearance of generally single, painless hemorrhagic blisters on oral mucosa not attributable to blood dyscrasias.¹ The diameters of lesion may range from 2 to 3 cm that commonly involves soft palate; however, other sites may be involved including buccal mucosa, lips, tongue border, epiglottis, and esophagus.^1,2 Clinically, the blisters start as dark red to purple, painless or rarely painful blisters that usually rupture, releasing blood mixed fluid, and leaving an eroded surface that heals without any treatment within 7 to 10 days.²

The etiology of ABH is uncertain. However, many predisposing factors have been identified; systemic diseases such as diabetes mellitus, hypertension and chronic renal failure, and local causes such as trauma, hot and spicy foods, dental procedures, and steroid inhalers.³ Common differentials of ABH include bullous lichen planus, bullous pemphigoid, thrombocytopenia, and epidermolysis bullosa. The diagnosis of ABH is mainly clinical and histopathology is not required. However, it is important to look for and treat the predisposing factors associated and differentiate it from other severe chronic disorders of the oral cavity to avoid unnecessary medications.