Haemorrhagic bullae in the oral mucosa with gingival bleeding

A 56 year old woman presented with a 2 day history of multiple painless violet haemorrhagic lesions on her gums, tongue, and buccal mucosa (fig 1⇓). This was associated with gingival bleeding, but there was no relevant medical history of comorbidity, medications, or local trauma. She was diagnosed with multiple haemorrhagic bullae. Blood tests done using fluorescence flow cytometry (Sysmex ​XS-1000i, Sysmex Corp. Japan) showed a platelet count of zero (reference range 150-400 ×109/L of blood). A manual platelet count was not performed. Coagulation, haemogram, and white blood cells tests were normal. A dermatological examination revealed further lesions on her chest and arms. She was treated with intravenous methylprednisolone (30 mg/kg/day) for seven days, and reached a count of 7 platelets ×109/L. Four days after the initial 7 day treatment, her platelets decreased rapidly to 3 ×109/L. The patient received a transfusion of 30×109/L platelets and prednisone (1 mg/kg/day). Five days after the transfusion, the woman left the hospital with a platelet count of 74 ×109/L.