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Angina Bullosa Hæmorrhagica
(Oral Blood Blisters)
Angina Bullosa Hæmorrhagica (Angina 'choking /
strangling',
bullosa 'a blister' & hæmorrhagica
'blood-filled',  initially termed as
traumatic oral
hæmophlyctenosis
) is the term used to describe
benign and generally,
sub-epithelial oral mucosal
blisters filled with blood, which are not attributable to a
systemic disorder or
hæmostatic defect (clotting
disorder).
The blood blisters may be confused with other more
serious disorders (e.g., dermatitis herpetiformis,
epidermolysis bullosa acquisita, mucous membrane
pemphigoid,
cicatricial pemphigoid, pemphigoid
amyloidosis
, blood dyscrasias) however, the isolated
nature, rapid healing and rare recurrence of
ABH blisters
generally are sufficient findings to rule out the previously
mentioned conditions.

The lesions maybe indistinguishable from blood blisters
related to low level of platelets (
thrombocytopænia)
however blood tests and the absence of areas of bruising
(
ecchymosis), nose bleeds (epistaxis) or bleeding from the
gums are helpful signs to rule it out.

Angina bullosa hæmorrhagica (ABH) is a rare acute and
benign blood blistering oral disorder that predominantly
affects middle-aged or elderly people (60% of the patients
in the range of 45 - 70 years).  Both sexes are equally
affected.
Photo of ABH on the left lateral border of the tongue
What are the causes of Angina Bullosa Hæmorrhagica (ABH)?

  • Slightly more than 50% of the cases described are related to the minor trauma
    of hot foods, restorative dentistry (fillings, crowns etc) or periodontal therapy
    (treatment of gum disease).

  • Other potential causes that have been mentioned in the literature are dental
    injections of anæsthetics and steroid inhalers.

  • A causative factor is not identified in almost 50% of patients.


Investigations:

Lab Studies:

  • Platelet counts and coagulation tests are within normal limits.

Procedures:

  • Performing a biopsy of an intact bulla is difficult because of the short duration
    of the lesion.

Histologic Findings:

  • The diagnosis is essentially clinical; however, in the cases in which a biopsy
    has being taken, the microscopic examination reveals a sub-epithelial bulla
    filled with blood and an underlying mild and non-specific mono-nuclear
    inflammatory cell infiltrate that generally is limited to the region of the lamina
    propria.

  • Performing a biopsy of an intact bulla is difficult because of the short duration
    of the lesion.  Otherwise, a biopsy of a ruptured bulla exhibits just a non-
    specific ulceration. According to Scully et al, direct immuno-staining for
    immunoglobulin G (IgG), immunoglobulin A (IgA), or C3 consistently are non-
    contributory.

  • However, laboratory tests are sometimes necessary to rule out any other
    bullous diseases.


Treatment:

Medical Care:

  • No treatment is required because the blood blisters spontaneously rupture and
    heal. Coagulation tests and platelet count may be indicated to rule out a blood
    dyscrasia.

Prognosis:

  • ABH is a benign condition.


Useful Websites & Articles:

Emedicine

New Zealand Dermatological Society (DermNZ)

British Medical Journal

Wikipedia

Index Medicus / PubMed



BMJ 1997.  Oropharyngeal Blood Blisters are known as Angina Bullosa
Haemorrhagica

Brit J Anaesth 2004.  Angina Bullosa Haemorrhagica presenting as Acute Airway
Obstruction

Folia Gastroenterol Hepatol 2005.  Traumatic Haemorrhagic Bullae of the Oral
Mucosa (Angina Bullosa Haemorrhagica)

J Oral Science 2008.  Angina Bullosa Hemorrhagica of the Soft Palate – A Clinical
Study of 16 Cases

Ind J Dermatol Venereol Leprol 2008.  Haemorrhagic Blisters in the Mouth

Asian J Oral Health & Allied Sciences 2012.  Case Report.  Angina Bullosa
Hemorrhagica - A Clinical Report

RFO 2012.  Angina Bullosa Haemorrhagica (ABH) - Diagnosis & Treatment

RSBO 2012.  Angina Bullosa Hemorrhagica - A Rare Condition
Last Updated 15th December 2014
Photo of ABH on the left soft palate
What are the signs and symptoms of Angina Bullosa Hæmorrhagica (ABH)?

Some patients describe a stinging pain or burning sensation immediately before the
appearance of the blood blister.  The blisters last only few minutes and then
spontaneously rupture, leaving a shallow ulcer that heals without scarring,
discomfort, or pain.

Patients do not report a tendency to bleed at other sites.

Family history generally is non-contributory (though there is a suggestion that it can
be associated with type II diabetes, hyperglycemia or a family history of diabetes
however there is no conclusive evidence of a cause-and-effect relationship
between the presence of
ABH and glucose metabolism).

Physical:

  • The lesions reach an average size of 1 - 3 cm in diameter.
  • The soft palate is the most commonly affected site.  Occasional lesions have
    been reported in the buccal mucosa and tongue (the anterior third is most
    commonly affected in the tongue).
  • Approximately one third of the patients exhibit blood blisters in more than one
    location.
  • The oral mucosa attached to bone (ie, ‘masticatory mucosa’ represented by
    the hard palate and gums) is not affected.
  • Similar lesions in other mucous membranes or the skin have not been reported.