The bleeding could occur while she was asleep and during times of physical activity and there was no obvious trigger for the bleeding. The bleeding occurred during times of perceived emotional stress and the episodes lasted from one to five minutes.
‘Hematohidrosis is an uncommon disease characterized by spontaneous discharge of “blood sweat” through intact skin.’
Blood Assessment For Factitious Disorder
The patient was assessed for factitious disorder. But the laboratory investigations including a complete blood count and coagulation studies (prothrombin time, activated partial thromboplastin time, fibrinogen and D-dimer) were normal. There was no evidence to support a diagnosis of factitious disorder.
As the patient had become socially isolated owing to embarrassment over the bleeding and symptoms consistent with major depressive disorder and panic disorder she was treated with paroxetine and clonazepam, but her bleeding continued.
During admission, the patient had discharge of blood-stained fluid from her face. Based on the presence of erythrocytes on microscopic examination (excluding disorders that induce "coloured sweat" secretion, such as chromhidrosis and pseudochromhidrosis), she was diagnosed with hematohidrosis. Histologic analysis of the skin in an area of bleeding was normal.
Hematohidrosis is an uncommon disease characterized by spontaneous discharge of "blood sweat" through intact skin. Various causes have been proposed, including systemic diseases, such as vicarious menses and coagulopathies (albeit historically reported in malaria, scurvy and epilepsy), exertion and psychogenic disorders, in which bleeding might be the result of exacerbated sympathetic nervous system activation.
In the literature, there is no single explanation of the source of bleeding in hematohidrosis. Despite the fluid's sweat-like appearance, the hypothesis that blood passes through eccrine ducts, induced by abnormal constrictions and expansions of periglandular vessels, has not yet been proven.
Bleeding has also reportedly occurred through areas without sweat glands or through the follicles, and the presence of dermal defects leading to blood-filled spaces exuding via follicular openings or directly into the skin surface has also been proposed.
The patient was treated with propranolol (20 mg/day), based on its use in similar cases in the literature, and this led to a marked reduction, although not a complete remission of her bleeding.