TJPRC: International Journal of Dermatology

and Cosmetology (TJPRC:IJDC)

Vol. 1, Issue 1, Dec 2016, 27-30
© TJPRC Pvt. Ltd.

ORAL BLEED IN DENGUE HEMORRHAGIC FEVER

SRIDHAR C1, C KRITHIKA2, SUDARSHAN R3 & UMAMAHESWARI S4

1
Professor of Internal Medicine, Government Thiruvarur Medical College, Thiruvarur, Tamil Nadu, India
2
Professor and Head department of Oral Medicine and Radiology, Thai Moogambigai
Dental College and hospital, Chennai, Tamil Nadu, India
3
Senior Lecturer, Department of Oral Medicine and Radiology, Thai Moogambigai
Dental College and Hospital, Chennai, Tamil Nadu, India
4
Postgraduate Trainee, Department of Oral Medicine and Radiology, Thai Moogambigai
Dental College and Hospital, Chennai, Tamil Nadu, India
ABSTRACT

A 30-year-old female patient presented with spontaneous bleed from the gingiva and the buccal mucosa for the
preceding 24 hours. Although afebrile during presentation, she gave a history of high-grade fever three days earlier,
which was controlled with Acetaminophen. Medical history was otherwise non-contributory. There were no symptoms to
suggest any other internal bleed. On examination, the vital signs were normal with no clinical evidence of cutaneous
bleeding. Oral examination revealed multiple small hematomas and ecchymotic patches in the palatal gingiva, buccal

Original Article
mucosa, lower labial mucosa and the floor of the mouth (Figure 1). Haemorrhagic crusting of the lower lip was seen with
a deep red hemorrhagic bulla in the left pterygomandibular raphae region (Figure 2). Laboratory investigations revealed
a drastically reduced platelet count of 25000 per cubic millimeter with an elevated hematocrit of 42%. No abnormalities
were detected on Chest radiograph and Ultrasound examination of the abdomen. Bone marrow aspiration ruled out
hematological malignancies. ELISA test for IgM antibody was positive for Dengue virus. So the case was diagnosed as
Thrombocytopenia secondary to Dengue hemorrhagic fever. The patient recovered in two weeks with platelet transfusions
and supportive care.

KEYWORDS: Dengue, Thrombocytopenia, Gingiva, Oral Hemorrhage, Platelet Count

Received: Sep 24, 2016; Accepted: Nov 15, 2016; Published: Nov 20, 2016; Paper Id.: TJPRC:IJDCDEC20165

INTRODUCTION

Prevalence of mucosal involvement is 15-30% in dengue hemorrhagic fever [1]. Platelet count falling
below 30,000 per mm3 produces spontaneous clinical hemorrhages [2]. Gingival bleeding is an uncommon
manifestation seen in Dengue Hemmorhagic fever [3]. Our case was even more unusual in that the oral mucosa was
the only site of hemorrhagic manifestation. In the oral mucosa, often the first sign of thrombocytopenia is gingival
bleeding followed by other mucosal sites such as the soft palate and buccal mucosa [2]. In general, gingival
bleeding can be caused by either local factors like poor oral hygiene and trauma[2,4] or systemic factors like
deficiencies of Vitamins C and K, anti-platelet and anti coagulant medications, immunological diseases like
sarcoidosis as well as collagen vascular diseases[4]. Oral hemorrhagic lesions may also be seen in hematological
diseases like Idiopathic Thrombocytopenic purpura, Leukemia, Von Willebrand’s disease and Hemophilia [4].
Blood filled blisters similar to our case are also seen in angina bullosa hemorrhagica and other traumatic
hematomas [5]. However both these conditions have no abnormal laboratory parameters. The presence of a few

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28 Sridhar C, C Krithika, Sudarshan R & Umamaheswari S

bullae in the posterior part of buccal mucosa that are intense red to black in color have been correlated with severe decrease
in the levels of platelet count[2].

The purpose of this paper is to prompt the clinicians to include the seldom considered Dengue hemorrhagic fever
in the differential diagnostic possibilities of oral hemorrhagic manifestations, particularly in tropical countries. This
awareness is especially important as bleeding in Dengue hemorrhagic fever can often manifest after the fever subsides
when the patient is apparently normal, as was in our case.

REFERENCES

1. Thomas EA, John M, Kanish B. Mucocutaneous manifestations of dengue fever. Indian J Dermatol. 2010; 55(1): 79–85.

2. Byatnal A, Mahajan N, Koppal S, et al. Unusual yet isolated oral manifestations of persistent thrombocytopenia – A rare case
report. Braz J Oral Sci. 2013; 12(3):233-236.

3. Singhi S, Kissoon N, Bansal A. Dengue and dengue hemorrhagic fever: management issues in an intensive care unit. J Pediatr
(Rio J). 2007;83(2 Suppl):S22-35

4. Gupta A, Epstein JB, Cabay RJ. Bleeding Disorders of Importance in Dental Care and Related Patient Management. J Can
Dent Assoc. 2007; 73(1):78-83.

5. Slezak R. Traumatic haemorrhagic bulla of the oral mucosa (Angina bullosa haemorrhagica). Folia Gastroenterol Hepatol
2005;3(4):122-127.

APPENDICES
Legends

Figure 1: Multiple Hemorrhagic Bullae and Ecchymotic Patches in the Lingual Gingiva,
Buccal Mucosa, Lower Labial Mucosa and the Floor of the Mouth on the Right Side

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Oral Bleed in Dengue Hemorrhagic Fever 29

Figure 2: Hemorrhagic Crust Involving the Lower Lip with a Hemorrhagic

Bulla in the Left Pterygomandibular Raphae Region

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