Angina Bullosa Hemorrhagica Clinical Presentation
- Author: Kara Melissa T Torres, MD, DPDS; Chief Editor: Dirk M Elston, MD more...
Angina bullosa hemorrhagica (ABH) is characterized by its sudden onset during or just after eating. The lesions may be preceded by stinging pain or a burning sensation, but they are essentially asymptomatic. A large bullae in the palatal region has been reported to give rise to a feeling of suffocation. Occasionally, patients may present with hoarseness or blood-tinged sialorrhea.
The blisters may last from a few minutes to 24-48 hours and then spontaneously rupture, typically during meals, releasing blood into the mouth. It usually leaves an erosion covered by epithelial slough that heals without scarring, discomfort, or pain within a week’s time. The lesions may appear intermittently or at regular intervals. The cases reported had a duration ranging from 4 months to 25 years.
Patients do not report a tendency to bleed at other sites.
Family history generally is noncontributory to angina bullosa hemorrhagica. Grinspan et al reported that 44% of his patients in a series of 24 cases published in 1999 had from type II diabetes, hyperglycemia, or family history of diabetes. No conclusive evidence of a cause-and-effect relationship exists between the presence of angina bullosa hemorrhagica and glucose metabolism.
The blister of angina bullosa hemorrhagica (ABH) appears tense, dark red to purple in color, and blood-filled surrounded by an ecchymotic halo. It has an average size of 1-3 cm in diameter. They are often solitary, but multiple lesions have been described.
Note the images below.
The soft palate is the most commonly affected site in angina bullosa hemorrhagica. Occasional lesions have been reported in the buccal mucosa, alveolar ridge, tongue, hard palate, and, rarely, the gingiva. If located on the tongue, the anterior third is most commonly affected. The vermillion border of the lips are almost always spared. Angina bullosa hemorrhagica also may involve the pharynx and the esophagus. Approximately one third of the patients exhibit lesions in more than one location.
Similar lesions in other mucous membranes or the skin have not been reported.
The described cases of angina bullosa hemorrhagica (ABH) had spontaneous onset or were related to minor trauma of ingestion of hot drinks ; hard, rough, and crispy foods[16, 6] ; restorative dentistry ; or periodontal therapy.
Other potential causes of angina bullosa hemorrhagica mentioned in the literature are dental injections of anesthetics[16, 18] ; steroid inhalers[19, 18] ; endoscopy ; trauma from the sharp edges of adjacent teeth, metal crowns, and prosthetic use[4, 20] ; tobacco consumption ; anticoagulant intake ; and coughing, sneezing, and shouting.[8, 6]
A report of 16 cases affecting the soft palate described hypertension as the most frequent underlying systemic condition (6 of 16 subjects); however, its relationship remains speculative, as hypertension is common in adults. Other reported associated systemic factors were diabetes mellitus, chronic kidney injury on hemodialysis, asthma, rheumatoid arthritis, gastrointestinal disturbances, hyperuricemia, and systemic lupus erythematosus.[8, 13, 14, 4, 11, 21]
In general, angina bullosa hemorrhagica is not attributable to blood dyscrasia, vesiculobullous disorders, or systemic diseases. A causative factor is not identified in approximately 47% of patients with angina bullosa hemorrhagica.
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