The New England Journal of MedicineSpontaneous Oral Purpura in Immune Thrombocytopenia

Unmasking the Silent Presentation: Spontaneous Oral Purpura as a Key Indicator in Immune Thrombocytopenia Diagnosis

A 76-year-old man’s unexpected encounter with blood-filled blisters on his tongue and purpura on his limbs unraveled a deeper medical narrative, culminating in the diagnosis of immune thrombocytopenia. This case underscores the significance of recognizing atypical presentations in diagnosing hematological disorders, serving as a pivotal learning point for clinicians.

Key Points:

• A 76-year-old patient presented with sudden, unprovoked hemorrhagic bullae on the tongue and gingiva, accompanied by purpura on extremities.
• Despite the absence of trauma or additional bleeding symptoms, the patient’s platelet count was critically low at 3000 per cubic millimeter.
• Comprehensive testing ruled out infections such as HIV, CMV, EBV, SARS-CoV-2, and hepatitis B and C, focusing the diagnosis on hematological abnormalities.
• The peripheral blood smear and bone marrow biopsy highlighted thrombocytopenia with an increased number of megakaryocytes, pivotal for diagnosing immune thrombocytopenia.
• Immune thrombocytopenia was diagnosed after excluding other causes of thrombocytopenia, emphasizing its nature as a diagnosis of exclusion.
• Treatment involved an 8-week tapering course of prednisolone, leading to the resolution of mucocutaneous lesions and normalization of platelet count by the 12-week follow-up.
• This case accentuates the rare occurrence where oral purpura is a primary manifestation of immune thrombocytopenia, highlighting the need for a thorough evaluation in atypical presentations.

Only a few cases of ITP have been reported in the oral medical literature. A literature search of PubMed using the keywords “idiopathic (or immune) thrombocytopenic purpura”, “bleeding”, “oral”, and “case report” from 1980 to 2015 revealed 12 articles that included 12 cases of ITP detected with oral hemorrhage as the first symptom in the English literature.

More in Hematology