style="font-size:15px;"> 5 No
Comments: Rendu‐Osler‐Weber syndrome can be easily excluded, as this is about having scattered telangiectasia since childhood, in contrast with the hemorrhagic spots (petechiae) that were found in this young lady. Asymptomatic petechiae are also seen on the soft palate and on margins of the hard with the soft palate after orogenital sex, which this lady had not reported. Asymptomatic palatal red spots are characteristics in nicotinic stomatitis, but the red spots there represent the inflamed duct openings of minor salivary glands and not petechiae. Palatal petechiae associated with general lymphadenopathy are also seen in patients with infectious mononucleosis, but the typically increased number of monocytes in the blood test and positive mononucleosis (mono) test, excludes this condition from diagnosis.
Q2 Which is/are the difference/s between petechiae and purpura?
1 Size
2 Location
3 Reaction to pressure
4 Symptomatology
5 Shape
Answers:
1 Petechiae are hemorrhagic spots with a diameter of <5 mm while purpura have a 5–9 mm diameter.
2 No
3 No
4 No
5 Petechiae have round, regular lesions while the shape of purpura and ecchymoses may be irregular.
Comments: Both hemorrhagic lesions do not blanch with pressure, are usually asymptomatic and can be found anywhere in the body.
Q3 What are the causes of thrombocytopenia apart from an HIV infection?
1 Leukemia
2 Epilepsy
3 Hepatitis C infection
4 Heavy alcohol consumption
5 Anorexia nervosa
Answers:
1 Thrombocytopenia is very common sign of an acute myelogenous and lymphocytic leukemia, as well as in advanced chronic lymphocytic and in progressive myelogenous leukemia. The reduced number of platelets has been attributed to: (i) bone marrow replacement by leukemic cells; (ii) increased destruction of platelets by swollen spleen or cytotoxic drugs for leukemia treatment; and (iii) immune destruction of platelets in some CLL cases.
2 No
3 Thrombocytopenia is a major problem in HCV+ patients as it interferes with various measurements for its diagnosis and follow‐up. The cause of thrombocytopenia is multifarious and is due to: (i) immunogenicity; (ii) direct bone marrow suppression; (iii) hypersplenism; (iv) decreased production of thrombopoeitin; and (v) drug reactions.
4 The chronic use of alcohol affects the production, survival time and functions of platelets while it also increases their destruction rate by an enlarged spleen leading to thrombocytopenia. The cessation of drinking within the second week raises the number of platelets again.
5 Anorexia nervosa causes thrombocytopenia. The reduced production of platelets is attributed mainly to low thrombopoietin rather than folic acid levels due to malnutrition.
Comments: Anti‐epileptic drugs such as valproate and levetiracetam but not the disease per se cause thrombocytopenia.
Case 1.10
CO: A 42‐year‐old man was admitted with gingival bleeding since the previous night.
HPC: The bleeding started suddenly after eating a snack with potato chips and became more intense and constant on the lower molar gingivae. No similar bleeding episodes had been reported previously by him or his close relatives.
PMH: Mild hypertension and cardiological problems were reported and controlled with diet and a heart mitral valve replacement five years ago, which was followed by daily use of the drug warfarin since then. Allergies or other systemic diseases and smoking or drinking habits were not recorded, while his diet was poor in green vegetables only.
OE: Spontaneous bleeding from all his gingivae but mainly from his lower left molars with incomplete clot formation was noticed. The clot was very soft and there was constant bleeding arising from the interdental papillae (Figure 1.10). This did not end with pressure, rinses with cold saline mouthwashes or antiseptics. A few petechiae were also seen near the occlusal lines of the buccal mucosae, but also in other mucosae or the skin. Cervical or systemic lymphadenopathy was also missing.
Q1 What is the main cause of gingival bleeding?
1 Local trauma
2 Dental plaque
3 Warfarin‐induced
4 Vitamin C deficiency
5 Liver cirrhosis
Answers:
1 Local trauma induced from hard foods such as potato chips could be a predisposing factor for gingival bleeding in patients regardless their oral hygiene status.
2 No
3 Warfarin is the main cause, as it blocks one of the enzymes that use vitamin K to produce clotting factors, thus causing incomplete clot formation similar to that was seen in this patient.
4 No
5 No
Comments: Dental plaque is responsible for gingival infection and bleeding in healthy and diseased patients, but it does not affect the clotting cascade. A vitamin C deficiency can cause alterations in collagen synthesis, making the small vessels of the gingivae weak and vulnerable to easy bleeding, either with a minor trauma or automatically. However, the patient's diet is correct, without any alcohol use and includes a great a number of foods that are rich in Vitamin C, apart from green fruits and vegetables which were excluded due to his warfarin uptake.
Q2 Which is/are the blood test/s used for checking a bleeding disorder?
1 WBC
2 D‐dimers
3 PT
4 A PTT
5 Vitamin D levels
Answers:
1 White blood count (WBC) is required to check
