Answers:
1 No
2 No
3 No
4 Angina bullosa hemorrhagica (ABH) is an acute, benign condition characterized by the development of subepithelial bullae filled with blood that are not attributed to any systemic disorders. A chronic trauma, consumption of hot and spicy or abrasive foods, or difficulties in restorative or periodontal treatment are considered to be the commonest causes.
5 No
Comments: Hemorrhagic bullae are often seen in other conditions such as thrombocytopenia, mucous pemphigoids and burns, but the presence of specific elements indicated the diagnosis. The appearance of low platelets and ecchymoses, epistaxis, and gingival bleeding in thrombocytopenia, the presence of numerous bullae with clear fluid in mucous pemphigoid, and the lack of close contact with thermal, chemical, or electrical elements in burns help to exclude these conditions from the diagnosis. Mucoceles are thicker and more resistant, while the bullae in angina are thinner and more easily break.
Q2 Which of the drugs below are usually related to the development of this condition?
1 NSAIDs
2 Antibiotics
3 Steroids
4 Anti‐diabetics
5 Bronchodilators
Answers:
1 No
2 No
3 Chronic use of steroids, especially inhalers, causes oral mucosa atrophy and decreases the submucosa's elastic fiber content, resulting in capillary breakdown locally, finally forming the characteristic hemorrhagic bullae.
4 No
5 No
Comments: Diabetes mellitus has also been associated with hemorrhagic bulla formation due to increased vascular fragility in these patients, and not to the drug for blood sugar reduction. Similar bullae could also be seen in patients who take antibiotics or bronchodilators and have various autoimmune diseases. As for NSAIDs, these drugs are responsible for peptic ulcers and bleeding from the intestine, but more rarely for skin bullous rash and fever.
Q3 Which of the histopathological finding(s) is/or are characteristics of this condition?
1 Subepithelial bulla
2 Intra‐epithelial abscess of neutrophils
3 Mononuclear inflammatory infiltration of submucosa deep to the muscles
4 Direct immunofluorescence negative
5 Eosinophils accumulation in the corium
Answers:
1 The breakage of the epithelial–connective tissue junction due to topical agents leads to local capillary hemorrhage and subepithelial bulla formation.
2 No
3 No
4 Direct immune‐fluorescence is always negative. DI is always positivein pemphigus and other intra‐epithelial blistering diseases.
5 No
Comments: The inflammatory response in ABH is intense and located only at the superficial parts of submucosa, often containing neutrophils but not eosinophils and mast cells.
Case 1.5
CO: A 48‐year old man was presented with a hemorrhagic lesion on the floor of his mouth.
HPC: The lesion appeared six months ago while the bleeding was noticed during eating three days ago.
PMH: No serious medical problems were recorded apart from an episode of severe pneumonia which was diagnosed last December and was treated with a strong course of antibiotics. No other drugs were taken, but the patient was a smoker (>40 cigarettes, daily) and a drinker (4–5 glasses of wine or relevant spirit per meal).
OE: The examination revealed an asymptomatic white lesion on the floor of mouth extended from the left lower premolar to the molar region. The lesion was fixed in palpation and had a warty‐like surface with two to three bleeding areas (Figure 1.5). Smoking‐induced lesions such as increased gingival pigmentation, nicotinic stomatitis and brown teeth discoloration were also found, together with ipsilateral, fixed, enlarged cervical lymph nodes where oral or skin petechiae and ecchymoses were not seen.
Q1 What is the cause of bleeding?
1 Traumatic ulceration
2 Pemphigus vegetans
3 Verrucous leukoplakia
4 Giant verruca vulgaris
5 Squamous carcinoma
Answers:
1 No
2 No
3 No
4 No
5 Squamous cell carcinoma is the cause of his oral bleeding. This tumor is a locally aggressive, tumor which appears as an indurated swelling, ulceration or plaque of various cellular differentiation and risk of metastasis. This lesion grows either slowly and superficially, but in majority of cases grows fast and invades deep tissues such as muscles and blood vessels causing muscle dysfunction and bleeding.
Comments: This tumor differs from other vegetating oral lesions such as hyperplastic traumatic ulcerations, pemphigus vegetans, verrucous leucoplakia, and verrucous vulgaris. The lack of local trauma or other vegetating lesions in the flexures of the patient rules out traumatic ulceration and pemphigus vegetans from the diagnosis, while the hard consistency and strong fixation of the lesion with the underling tissues is not an indication of verrucous vulgaris and leukoplakia where biopsy is required.
Q2 Although the verrucous carcinoma is a variation of oral carcinomas, it differs from the other types in the following histological characteristics:
1 Evidence of dysplasia in adjacent epithelium
2 Shape of the rete pegs
3 Absence of keratinization
4 Location of mitosis
5 Basal basement membrane status
