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Letters to the Editor
metaplastic phenomenon.[4] Dermal vacuoles may be
seen within areas of dense dermal inflammation due
to extracellular lipid deposition. In acrodermatitis
chronica atrophicans, vacuoles in the upper dermis
have been described in the setting of dermal sclerosis
and have been attributed to lymphedema and the
presence of prelymphatics that are walled off by
ground substance and have no lining.[5]
Unlike the above situations, pseudo‑lipomatosis cutis
is an unusual dermal artifact unrelated to underlying
pathologic processes and is postulated to occur due to
injection of air during administration of local anesthetic
prior to the biopsy procedure. Another proposed etiology
for this artifact is the formation of gas in the tissue due
to inadequate fixation with autolytic changes and gas
bubble formation leading to empty spaces in the tissue.[6]
Rajiv Joshi
Department of Dermatology, P.D. Hinduja Hospital and MRC, Mahim,
Mumbai, Maharashtra, India
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1. Trotter MJ, Crawford RI. Pseudolipomatosis Cutis: Superficial
dermal vacuoles resembling fatty infiltration of the skin. Am J
Dermatopathol 1998;20:443‑7.
2. Snover DC, Sandstad J, Hutton S. Mucosal pseudo‑lipomatosis
of the colon. Am J Clin Pathol 1985;84:575‑80.
3. Alper M, Akcan Y, Belenli OK, Cukur S, Aksoy KA, Suna M.
Gastric pseudo‑lipomatosis, usual or unusual? Re‑evaluation
of 909 endoscopic gastric biopsies. World J Gantroenterol
2003;9:2846‑8.
4. Maize JC, Foster G. Age‑related changes in melanocytic naevi.
Clin Exp Dermatol 1979;4:49‑58.
5. Brehmer‑Andersson E, Hovmark A, Asbrink E. Acrodermatitis
chronica atrophicans: Histopathologic findings and
clinical correlations in 111 cases. Acta Derm Venereol
1998;78:207‑13.
6. Thomson SW, Luna LG. An atlas of artifacts encountered in the
preparation of microscopic tissue sections. Springfield Illinois:
Charles C. Thomas Publisher; 1978.p. 24.
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DOI:
10.4103/0378-6323.162336
Address for correspondence: Dr. Rajiv Joshi,
14 Jay Mahal, A Road, Churchgate,
Mumbai - 400 020, Maharashtra, India.
E-mail: [email protected]
Palatal ecchymosis associated
with irrumation
Sir,
Oral injuries from trauma due to mechanical, chemical
or thermal factors are an important cause of oral mucosal
disease. Traumatic lesions clinically present in various
forms including ulcers or erosions, hemorrhagic
lesions, keratotic patches and hyperplastic growths.
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26261144
There was no history of thermal or chemical
trauma. However, in the past few months she had
experienced similar lesions on the palate, which
usually disappeared within a week to 10 days.
She reported that she had been giving oral sex to
her husband for the past one year. After clinical
examination, a routine blood investigation showed all
parameters within normal limits. Based on the above
findings, the lesion was diagnosed as irrumation or
fellatio‑associated ecchymosis of the hard palate.
The patient was educated and reassured. Follow‑up
Hemorrhagic lesions that occur following oral trauma
include petechiae (<2 mm in diameter), purpura (2 mm
to 1 cm in diameter) and ecchymosis (larger than 1 cm in
diameter).[1] Here, we describe a case of palatal ecchymosis
following mechanical trauma. The differential diagnosis
of palatal hemorrhagic lesions is also highlighted.
A healthy 28‑year‑old woman attended for regular dental
checkup. Examination of her oral cavity revealed a
non‑elevated, painless, diffuse area of ecchymosis with
irregular borders measuring approximately 2 × 1.5 cm on
the left side of the hard palate [Figure 1]. The lesion did
not blanch under pressure. Concurrently, no other similar
lesions were found elsewhere in her mouth or body.
Figure 1: Ecchymotic lesion on the hard palate
Indian Journal of Dermatology, Venereology, and Leprology | September-October 2015 | Vol 81 | Issue 5
505
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after 2 weeks showed complete disappearance of the
lesion.
Irrumation or fellatio is a sexual act in which the penis is
placed into the mouth of another person, the “recipient
sexual partner”, also known as oral intercourse.
Clinical presentations of fellatio‑associated traumatic
blood vessel injuries of the palate include ecchymoses,
petechiae, purpura, hemorrhage, erythema and
palatitis. These lesions are either acute or chronic and
are more prevalent in young women. They usually
appear on the soft palate but can also develop at the
junction of the hard and soft palate and rarely on the
hard palate.[2,3]
Fellatio‑associated oral lesions are under‑reported given
the recent increased acceptability of oral sex. These
lesions are often asymptomatic and usually go unnoticed
by the affected individual. Hence, they are seldom
brought to the attention of a physician or a dentist.
The pathogenesis of fellatio‑associated palatal
hemorrhagic lesions is multifactorial. Direct and
forceful contact of the distal penis against the
palate may result in mucosal injury with rupture of
submucosal vessels and hemorrhage, or it may be
secondary to an intense reflex palato‑pharyngeal
spasm brought on during fellatio. The concurrent
negative pressure created through irrumation has a
major contributory role in the mechanism of injury.
Occasionally these lesions may be associated with
secondary candidal infections.[2,4]
On most occasions, the diagnosis can be established
through history and clinical examination. However,
the clinical presentation of fellatio‑associated
traumatic injuries varies significantly and they must
be differentiated from other hemorrhagic lesions
on the palate. Hemorrhagic lesions on the palate
that are persistent with expanding margins, or are
multiple may require further evaluation. Table 1 gives
the differential diagnoses for palatal hemorrhagic
lesions, showing both the generalized and localized
causes.[2,5,6] If a diagnosis of trauma cannot be
established, additional evaluation like complete blood
investigation to check for blood dyscrasias, serologic
studies and cultures to confirm viral and bacterial
infections and radiography to rule out tumors and
maxillofacial fractures may be performed. Biopsy is
rarely required for histopathological confirmation of
diagnosis.
506
Table 1: Palatal hemorrhagic lesions
Generalized
Disseminated intravascular coagulation
Hemophilia
Idiopathic thrombocytopenia purpura
Leukemia
Capillary fragility
Infectious mononucleosis
Measles
Dengue viral infection
Anticoagulant therapy
Aspirin
Antithrombolytic therapy
Hereditary hemorrhagic telangiectasia
Vitamin C deficiency
Localized
Streptococcal infections
Upper respiratory infections
Playing a wind instrument
Injuries caused by violent coughing, sneezing, vomiting
Suction
Fractures involving the maxillofacial area
Blunt trauma
Chemical ingestion
Fellatio
Intubation for general anesthesia
Nasogastric tube insertion and feedings
Piercing and penetrating trauma
Thermal injury
Tumors
Fellatio‑associated hemorrhagic lesions resolve
spontaneously and treatment is usually not necessary.
In conclusion, fellatio‑associated palatal ecchymoses
occur usually in young women. They are asymptomatic
and often the patient does not discover the lesion until
several hours or days following the causative event.
These lesions are generally straightforward to diagnose
and hence easy to manage by elimination of the causative
factor. Evaluation of patients for sexually transmitted
diseases should be considered in appropriate situations.
Kavitha Muthu, Sathya Kannan,
Senthilkumar Muthusamy1, Preena Sidhu2
Departments of Oral Pathology, 1Periodontology,
Faculty of Dentistry, AIMST University, Bedong, Kedah,
2
Endodontics, SEGi University, Kuala Lumpur, Malaysia
Address for correspondence: Dr. Kavitha Muthu,
Department of Oral Pathology, Faculty of Dentistry, AIMST
University, Bedong 08100, Kedah, Malaysia.
E‑mail: [email protected]
Indian Journal of Dermatology, Venereology, and Leprology | September-October 2015 | Vol 81 | Issue 5
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Letters to the Editor
REFERENCES
1. Kumar V, Abbas AK, Fausto N, Mitchell RN. Robbins Basic
Pathology, 8th Ed. Philadelphia: Saunders Elsevier; 2007.
2. Cohen PR, Miller VM. Fellatio‑associated petechiae of the
palate: Report of purpuric palatal lesions developing after oral
sex. Dermatol Online J 2013;19:18963.
3. Damm DD, White DK, Brinker CM. Variations of palatal
erythema secondary to fellatio. Oral Surg Oral Med Oral Pathol
1981;52:417‑21.
4. Giansanti JS, Cramer JR, Weathers DR. Palatal erythema:
Another etiologic factor. Oral Surg Oral Med Oral Pathol
1975;40:379‑81.
5. Cienfuegos R, Sierra E, Ortiz B, Fernández G. Treatment of
palatal fractures by osteosynthesis with 2.0‑mm locking
plates as external fixator. Craniomaxillofac Trauma Reconstr
2010;3:223‑30.
6. Thomas EA, John M, Bhatia A. Cutaneous manifestations of
dengue viral infection in Punjab (north India). Int J Dermatol
2007;46:715‑9.
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*****
Matchbox sign: Look before you
label!
Sir,
In a typical clinical vignette, patients of delusion
of parasitosis or delusional infestation present with
“evidence of parasites” collected in a container. This
“matchbox sign” or “specimen sign” is useful to make the
diagnosis, with a proviso that the material presented to
the physician has been carefully examined and found
to be normal skin pieces or extraneous material.[1]
A 26‑year‑old, unmarried female presented with
a 20 days history of pruritus over legs, arms, and
abdomen and a feeling of insects crawling all over
her body. Except for a few excoriation marks, she
had no other signs on the skin. She had consulted
two dermatologists previously, where she was
diagnosed as a case of delusion of parasitosis and put
on antidepressants. Further, she took out a matchbox
from her purse to show us the “insects.” Grossly, they
looked like tea particles in the match box. Hand lens
examination made us suspicious and microscopic
examination revealed reddish brown creatures
with eyes, head, thorax, laterally compressed
abdomen and bristles on legs. [Figure 1]. On further
detailed study we identified them as cat‑fleas, that
is Ctenocephalides felis. The patient had a pet cat
which ran away about a month back for 5 days and
she correlated her symptoms to the cat’s return. She
was treated with antihistamines and calamine and
advised to take her cat to a veterinary physician
and contact a pest control agency for flea control
at home. After 1 week, her symptoms had subsided
completely.
Figure 1: Cat flea (Ctenocephalides felis) with its characteristic
pronotal and genal combs (×400)
The “matchbox sign” is typical of delusional
infestation.[1] However, as our case underlines, we
should not be in a hurry to label the patient delusional,
unless the “evidence” presented in the matchbox has
been meticulously examined. The history of pets in
the house or contact with animals must be considered
in all cases of idiopathic pruritus. There is a paucity
of articles on fleas in Indian dermatology journals,
reflecting the low awareness.
Important fleas and their identifying characteristics are
summarized in Table 1.[2] Fleas are small (about 1–8 mm),
hard, wingless insects of order Siphonaptera. These
avian and mammalian ectoparasites are attracted to
the host in response to carbon dioxide, vibrations and
temperature. The life cycle evolves through stages of
egg, larvae, pupae and the adult flea.[3,4]
On the skin, they cause papular urticaria
preferentially on the lower limbs. Hypersensitivity
Indian Journal of Dermatology, Venereology, and Leprology | September-October 2015 | Vol 81 | Issue 5
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