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Thrombocytopenic purpura
ORAL .
.
MEDICINE .
.
.
.
THROMBOCYTOPENIC Report
of a Case
.
.
.
.
.
PURPURA
.
.
.
.
.
.
.
.
.
.
..a
The diagnosis oil throln~)oc.~tol,cuic p~~y~ra is 111at1con the basis of tjll(h histoy, physical csamimrtion ( cnlargcd and eongwtcltl splwn) , and laboratorytests. The henrwtologic findings reveal ( 1) an Cole\-at-cdbleeding time that vangrs from scow miuntes to an hour or more, (2) rcdnction in blood platelet count lo below 50,000 per cubic millimeter, (3) norn1al clotting I-imc, (41 poor clot retraction, and (5) increased capillary frapility. The dental practitioner who suspects a blood dyscrasia from both the history and clinical cbsamination may make thiw simpl(l lahoratoq- tests in the office to determinr whether the patient shonld be referred to a physician for a more clahorate csamination. The first, test is tllc bleeding time dctcrminat.ion which consists of prickin g the skin of the finqr alid rioting thr prccisc time iit which blcrding ceases, as detcrmincct 1)~ tollcllin~ 111(1blood from the wountl the fi1tcr paper ccas(‘s c\wy- few seconds with a picce of filter paper. \\TllCll The Il(Jl’lll~l~ value is one to thiw to bc stained, the blreding time is cstablishcd. minutes. The second test is the dctcrmination ot’ thch cwagulation timcl. l’hc Lee-White test consists of the collection of 1 C.C.of int wvcnowi blood in a (a1wn test tnbc 8 mm. in diameter. The eoagnlation tinrc is the time ihatS clapscs from the moment the blood was shctl to the time it cong~~:~ls.as indicated 1~ tilting the tube. The normal valnc is six to fifteen minnirs. The thirtl test is A blood pwsthe Kwnpel-Leede t’est,, which dctcrminos the capillary fragility. sure cuff is placed about the upper arm and inflated to tlw mean val~lc bctwccn t,he systolic and diast,olic ~~css~I’~s, and 1~~1~1 tlrerc for ti\.c minldcs. The al’pearance of a large number of petechiae distal to the obstt~nction in a 2.5 cm. diamctcr circle is indicative of capillary fragility. ~!bnormal \-alucs in thcsc simple tests should alert the dentist to the possibilit,y oC a blood dyscrasia. The following report ~110~s the scriousncss of a CIIX of prc\+)uslp 11ndiagnosed thromhocytopenic, purpnra. (:.\SE
REPORT
F. L., a 5SycxrWld K-ego ‘ivOIll:tll, was seen at the or:11 surger?- clinic of the ?rZetropolitan Hospital with a chief complaint of l~leeding from the mouth. ~!Fistory of Present IIlJIc ss-One day prior to adrrlissi~~rl, tile patient notied 1defrdin.g from her gingivae upon rumoring her dentures. On the day of admission, she noticetl “111ack and blue” spots on h(sr arms (Fig. I) 2nd body. The patient stated that this was the first q)isode of bleeding f ram the mouth and the first time tll:lt ccchymotic spots llild ;tppeard. CZilzicd Ezami,zntioll.--Examillation of the oral c:rvit>- rcrr~alcd two large, macul;ar, nonpainful ecchymotiv areas on the palate (Pig. 2), one area of wchymosis on the left cheek (Fig. 3 j, and petechiw on twtll upper (Fig. 4) and lower lips and on the undersurface of tcsl the tongue (Fig. 5). l+:cl~ymot iv areas wwc prewnt on lloth arms. The Rurnpel-Leede proved positive for capillary fragility. lllceding time n-as recorded at eight minutes. A clinical diagnosis of tl~roml~ocyto~Pnil: lnxpura was made and immediate medical cow sultation was sought. Past Distoy.-The patient reported that she 1~~1 had the usual childhood diseases, lues, and heart disease. Ten years earlier she was hospitalized with pain in the precordial
Fig.
4.
--lGx~h~nlr,tic a.w~.s on Ilal;i.te. b’iu. :{.--l,:CCIl.vrHi,tiC area of IsIft chwk. Fix.
I!.
Fig.
4.
--I’vtc~~hiwc
on
Vip. .I.-l~:r~~~ll~lrlotic SUM\II1IARY
.ZSD
upper
liu.
Wl’Piw on untler~s~lrfucc
of
tongue?
and
loner
lip
CONCLUSIOS
A twnparatively rare case of fulminating tllronil)ocytop,ellic purpura has been presented. Recausc of the patient’s age and the previous reports in the literature linking an allergy to drugs (phenobarbital, for example) as one of the etiological facbors it was felt that this case should be classified as secondary thromboeytopenic purpura. The physical examination, history, clinical appearance, and laborat.ory data conclusirely pointed to such a diagnosis. The author gratefully of Metropolitan Hospital.
acknowledges
the assistance
of the medical
and pathology
services
KEFEKESCES Basis of Medical Praci iw, (‘(1. 1. llnst,, Charles H., and Taylor, Norman R. : Physiological 6, Baltimore, 1955, Williams $ \\‘ilkius Company. 2. Boyd, William: Textbook of Pathology, rd. 6, Philadelphia, 1953, Lea & $‘cl~igw. 3. Burket, Lester IV.: Oral Medicine, ed. 2, Philadelphia, 1952, J. B. Lippincott Company. 4. Cecil, Russell L., and Loeb, Robert F. : A Textbook of Medicine, ed. 10, Philndclphia, 1959, ‘IV. B. Saunders Company. Signs :11111Symptoms, ~1. 3, I’llil:l~l~~l~~lli:~, 1937, ,T. I<. Lipl~incol! 5. MacRryde, Cyril XI.: Company.
.
MEDICINE .
.
.
.
THROMBOCYTOPENIC Report
of a Case
.
.
.
.
.
PURPURA
.
.
.
.
.
.
.
.
.
.
..a
The diagnosis oil throln~)oc.~tol,cuic p~~y~ra is 111at1con the basis of tjll(h histoy, physical csamimrtion ( cnlargcd and eongwtcltl splwn) , and laboratorytests. The henrwtologic findings reveal ( 1) an Cole\-at-cdbleeding time that vangrs from scow miuntes to an hour or more, (2) rcdnction in blood platelet count lo below 50,000 per cubic millimeter, (3) norn1al clotting I-imc, (41 poor clot retraction, and (5) increased capillary frapility. The dental practitioner who suspects a blood dyscrasia from both the history and clinical cbsamination may make thiw simpl(l lahoratoq- tests in the office to determinr whether the patient shonld be referred to a physician for a more clahorate csamination. The first, test is tllc bleeding time dctcrminat.ion which consists of prickin g the skin of the finqr alid rioting thr prccisc time iit which blcrding ceases, as detcrmincct 1)~ tollcllin~ 111(1blood from the wountl the fi1tcr paper ccas(‘s c\wy- few seconds with a picce of filter paper. \\TllCll The Il(Jl’lll~l~ value is one to thiw to bc stained, the blreding time is cstablishcd. minutes. The second test is the dctcrmination ot’ thch cwagulation timcl. l’hc Lee-White test consists of the collection of 1 C.C.of int wvcnowi blood in a (a1wn test tnbc 8 mm. in diameter. The eoagnlation tinrc is the time ihatS clapscs from the moment the blood was shctl to the time it cong~~:~ls.as indicated 1~ tilting the tube. The normal valnc is six to fifteen minnirs. The thirtl test is A blood pwsthe Kwnpel-Leede t’est,, which dctcrminos the capillary fragility. sure cuff is placed about the upper arm and inflated to tlw mean val~lc bctwccn t,he systolic and diast,olic ~~css~I’~s, and 1~~1~1 tlrerc for ti\.c minldcs. The al’pearance of a large number of petechiae distal to the obstt~nction in a 2.5 cm. diamctcr circle is indicative of capillary fragility. ~!bnormal \-alucs in thcsc simple tests should alert the dentist to the possibilit,y oC a blood dyscrasia. The following report ~110~s the scriousncss of a CIIX of prc\+)uslp 11ndiagnosed thromhocytopenic, purpnra. (:.\SE
REPORT
F. L., a 5SycxrWld K-ego ‘ivOIll:tll, was seen at the or:11 surger?- clinic of the ?rZetropolitan Hospital with a chief complaint of l~leeding from the mouth. ~!Fistory of Present IIlJIc ss-One day prior to adrrlissi~~rl, tile patient notied 1defrdin.g from her gingivae upon rumoring her dentures. On the day of admission, she noticetl “111ack and blue” spots on h(sr arms (Fig. I) 2nd body. The patient stated that this was the first q)isode of bleeding f ram the mouth and the first time tll:lt ccchymotic spots llild ;tppeard. CZilzicd Ezami,zntioll.--Examillation of the oral c:rvit>- rcrr~alcd two large, macul;ar, nonpainful ecchymotiv areas on the palate (Pig. 2), one area of wchymosis on the left cheek (Fig. 3 j, and petechiw on twtll upper (Fig. 4) and lower lips and on the undersurface of tcsl the tongue (Fig. 5). l+:cl~ymot iv areas wwc prewnt on lloth arms. The Rurnpel-Leede proved positive for capillary fragility. lllceding time n-as recorded at eight minutes. A clinical diagnosis of tl~roml~ocyto~Pnil: lnxpura was made and immediate medical cow sultation was sought. Past Distoy.-The patient reported that she 1~~1 had the usual childhood diseases, lues, and heart disease. Ten years earlier she was hospitalized with pain in the precordial
Fig.
4.
--lGx~h~nlr,tic a.w~.s on Ilal;i.te. b’iu. :{.--l,:CCIl.vrHi,tiC area of IsIft chwk. Fix.
I!.
Fig.
4.
--I’vtc~~hiwc
on
Vip. .I.-l~:r~~~ll~lrlotic SUM\II1IARY
.ZSD
upper
liu.
Wl’Piw on untler~s~lrfucc
of
tongue?
and
loner
lip
CONCLUSIOS
A twnparatively rare case of fulminating tllronil)ocytop,ellic purpura has been presented. Recausc of the patient’s age and the previous reports in the literature linking an allergy to drugs (phenobarbital, for example) as one of the etiological facbors it was felt that this case should be classified as secondary thromboeytopenic purpura. The physical examination, history, clinical appearance, and laborat.ory data conclusirely pointed to such a diagnosis. The author gratefully of Metropolitan Hospital.
acknowledges
the assistance
of the medical
and pathology
services
KEFEKESCES Basis of Medical Praci iw, (‘(1. 1. llnst,, Charles H., and Taylor, Norman R. : Physiological 6, Baltimore, 1955, Williams $ \\‘ilkius Company. 2. Boyd, William: Textbook of Pathology, rd. 6, Philadelphia, 1953, Lea & $‘cl~igw. 3. Burket, Lester IV.: Oral Medicine, ed. 2, Philadelphia, 1952, J. B. Lippincott Company. 4. Cecil, Russell L., and Loeb, Robert F. : A Textbook of Medicine, ed. 10, Philndclphia, 1959, ‘IV. B. Saunders Company. Signs :11111Symptoms, ~1. 3, I’llil:l~l~~l~~lli:~, 1937, ,T. I<. Lipl~incol! 5. MacRryde, Cyril XI.: Company.