Recurrent oral hemorrhage in a cat – an unusual etiology

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Apr 01, 2010

Oral hemorrhage is an uncommon clinical finding when it occurs spontaneously without a history of trauma. Nontraumatic oral bleeding can be due to neoplasia, periodontal disease and, in the case discussed below, what appears to be several factors. Frank and significant hemorrhage as seen in this case is particularly unusual.

A curious case

A white domestic shorthaired cat was presented to a local emergency facility for evaluation of spontaneous oral bleeding. No abnormalities other than frank oral hemorrhage were noted on presentation. The patient was sedated, and an oral examination revealed arterial hemorrhage associated with a diffuse palatal defect 3 mm palatal to the right maxillary canine tooth. A suture was placed into the palatal tissue and successfully stopped the hemorrhage. The patient was kept for observation and then discharged some time later.


Photo 1: Three palatal lesions are evident. The lesion adjacent to the canine tooth was the origin of the bleeding. (Photos: Courtesy of Dr. Brett Beckman)
Less than 48 hours later, the patient was presented again to the emergency facility with the same complaint. Sedation and suturing were repeated at the same site, although this time a horizontal mattress suture was placed. A recommendation was made for referral the next morning to determine a cause for the recurrent spontaneous hemorrhage.


Photo 2: A palatal mucosal flap was used to visualize the bone adjacent to the defect, ligate the major palatine artery and obtain biopsy samples of the lesion.
On physical examination at the referral clinic, numerous fleas, pink staining of the coat in multiple locations about the torso and limbs and dried blood within and about the oral cavity were noted. The owners were queried and confirmed that the cat groomed excessively, but they were not aware of the flea infestation. The results of a complete blood count, serum chemistry profile, T4 concentration measurement and feline leukemia virus and feline immunodeficiency virus testing revealed a slight anemia (PCV = 23.7%), mild hypoglobulinemia and a mild decrease in the T4 concentration. While awaiting sedation and a complete oral examination, the patient's oral hemorrhage returned, with arterial blood dripping freely from the oral cavity.


Photo 3: The major palatine artery is seen here after surgical exposure.
The patient was sedated, and an oral examination revealed bleeding associated with the palatal lesion. The tissue associated with the lesion was dark-red and lacked palatal ruggae (Photo 1). Two additional smooth darkened lesions were present in the caudal palatal mucosa.


Photo 4: The flap is sutured after ligation.
Because of the recurrence and severity of the hemorrhage, ligation of the major palatine artery was indicated to eliminate the major arterial supply to the tissue. A full-thickness palatal flap was used to expose the bone adjacent to the lesion for visualization and to isolate the artery for ligation (Photos 2 and 3). The bone and adjacent palatal tissue appeared normal. Biopsy samples were then taken of the bleeding lesion and one of the caudal palatal mucosal lesions. The flap was closed by using a simple interrupted suture technique (Photo 4). Eosinophilic granuloma and neoplasia were considered the most likely rule-outs. Histopathology was nonspecific and revealed well-differentiated hyperplastic epithelial cells. Pruritic dermatitis secondary to flea infestation was diagnosed based on the clinical signs and was resolved with flea treatment and an anti-inflammatory dose of prednisone given every other day.


Photo 5: The patient at a recheck showing the resolving lesions.
The patient returned in six weeks for a recheck. No additional bleeding was observed, and external parasites were absent. Evidence of all three lesions was still present, but the lesions appeared to be resolving and not clinically active (Photo 5).