BLOODY SWEAT : A RARE FRIGHTENING CONDITION

BLOODY SWEAT : A RARE FRIGHTENING CONDITION
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Introduction:

Hematidrosis or hematohidrosis or bloody sweat is a rare and self-limiting condition characterized by blood oozing from the intact skin and mucous membranes in the absence of any bleeding problem.1It commonly affects young females of Asian ethnicity. Bleeding most commonly occurs from the ear, nose, oral cavity and other facial areas.2 Unusual anxiety, fear or stress factor play a major role in the starting of symptoms.3 Here we present a 15-year-old girl who presented with similar complaints and was diagnosed as a case of hematidrosis after ruling out other bleeding diathesis.

Case presentation:

Miss X, a 15-year-old girl from Tiruvallur, studying class XI presented to ENT department with spontaneous bleeding from both the ears on and off for the last one month. She was seen multiple times for similar complaints at local hospital in Tiruvallur. She also had 2 episodes of bleeding from the tongue and spitting of blood and one episode of bleeding from the right ear. Evaluation at local hospital showed normal platelet count, bleeding time, PT/INR and APTT values at different time intervals. She was managed conservatively with tranexamic acid and Inj.Vitamin K. ENT evaluation at our hospital confirmed bleeding from the left external auditory meatus. However, there was no ulcerations, infection or dilated blood vessels at the site of bleeding. There was no bleeding in the nostrils or oral cavity. She was referred to hematology department to rule out bleeding diathesis.

There was no history of fever, recurrent infections or contact with tuberculosis patients. There was no history of bleeding manifestations in the past or in any of the family members. She is first born child to non-consanguineous parents. All these bleeding episodes occurred spontaneously without any injury or trauma. On observation in OPD, there was bleeding from the left ear. However, it was more diluted and felt like it was mixed with water.

Complete coagulation profile was done in CMC Vellore which showed normal hemoglobin, platelet count and platelet morphology. Bleeding time and PFA closure time were normal. Prothrombin Time, Activated Partial Thromboplastin Time, Fibrinogen and Thrombin Time were normal. Coagulation factor VIII, IX, XI and vWF:RCo were normal. ROTEM study was also normal suggesting that the patient had no intrinsic hemostatic defect.

Figure 1. Patient bleeding from left ear.

Detailed history with the patient revealed that she was forced to change her schooling in June 2024 for her class XI. She also reported experiencing frequent scoldings from her father regarding her excess usage of mobile phone. All the above bleeding symptoms started in July 3rd week confirming the stress factor behind the start of symptoms. She was diagnosed as a case of hematidrosis. Family education and psychotherapy was given. She was also given Tab Propranolol to relieve her symptoms. Video consultation in January 2025 with the patient revealed that she did not have any further episodes at home, and she had stopped propranolol after 2 months.

Discussion:

Hematohidrosis or Blood sweat is a rare condition and the largest report available report by Kluger et al had only 25 cases from 1996 to 2016. This condition is most commonly reported in females (84%) with a median age of 13 years (Range 9-72 years).2 In our case also, the affected patient was a 15-year-old female with undue stress from family. The episodes last for few minutes and resolve spontaneously without any intervention, 3The exact pathophysiology is still unknown. It is presumed to be caused due to disruption of microvessels around the sweat glands on sympathetic nervous system hyperactivation, with stress being the precipitating factor. 2 There is no definitive diagnostic criteria for this disorder. The features which give a clue to the diagnosis are (i) completely normal coagulation work up, (ii) absence of trauma and (iii) excellent response to beta blockers/ anti anxiolytics or psychotherapy .4 Our patient also had good responses to propranolol and psychotherapy. Atropine sulfate transdermal patches have been used in the past. Although the bleeding is usually self limited, sometimes this condition can cause serious side effects like dehydration.5

Conclusion:

Hematohidrosis can be a frightening experience for patients and their caregivers. Reporting these cases can create awareness among physicians about this benign yet rare condition. It will also help in avoiding accusation of factitious disorder for a family that is already in need of medical help for this rare disorder.

References:

  1. Alsermani, M., Alzahrani, H., & El Fakih, R. (2017). Hematidrosis: A Fascinating Phenomenon—Case Study and Overview of the Literature. Seminars in Thrombosis and Hemostasis, 43(8), 753-757. doi: 10.1055/s-0037-1608905
  2. Sha Y, Yoshimura H, Saito S, Kitoh R, Takumi Y. A case of hematohidrosis successfully treated with a beta- blocker. Clin Case Rep. 2023;11:e7337. doi:10.1002/ ccr3.7337
  3. Badry, M. S., Elbadry, M. I., Ragab, A. R. A., & Ahmed, M. E. (2020). Hematohidrosis: Reports and Update of Clinically Mysterious Phenomenon. Indian Journal of Otology, 26(2), 99-102. doi:10.4103/indianjotol.INDIANJOTOL_135_19
  4. Alasfoor S, Albashari M, Alsermani A, Bakir M, Alsermani M, Almustanyir S. A Strange Occurrence of Hematohidrosis: A Case Report From Saudi Arabia. Cureus. 2022 Jan 28;14(1):e21682. doi: 10.7759/cureus.21682.
  5. Hematohidrosis: A Mysterious and Rare Disorder. Archives of NIMH, 2020; 3(2): 40-42.

 

Ms. Kanumoori Angelin
Physician Assistant
Kauvery Hospital, Chennai

 

 

Mr. Sankaralingam
Physician Assistant
Kauvery Hospital, Chennai