Open Access Case Report Hematohidrosis Pak Armed Forces Med J 2019; 69 (3): 730-32 HEMATOHIDROSIS–A RARE KNOCKER AT OTOLARYNGOLOGIST’S DOOR Kamran Zamurrad Malik, Ameer Abdullah, Tarique Ahmed Maka* Combined Military Hospital Nowshere Pakistan, *Combined Military Hospital Risalpur Pakistan ABSTRACT Hematidrosis or hematohidrosis is an extremely rare clinical phenomenonin which a spontaneous recurrent painless and self-limited bleeding from skin in any part of the body, with diverse causal etiologies and inconstant success to different current management modalities. Our case studies report the clinical finding of two cases of a very rare ontological hematohidrosis. It is an extremely rare medical condition, with very few cases reported in literature. Keywords: Hematohidrosis, stress, propranolol. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. INTRODUCTION confirmed by health professional and the exis- Hematidrosis represents a strange and tence of blood components on biochemistry extremely rare medical condition where the studies of the discharge withnormal lab inves- affected individual literally sweats bloody fluid tigations4. through the sweat pores. The skin is usually Hematidrosis rarely causes serious side anatomically and histologically normal, having effects, though some people experience dehy- no evidence of trauma anywhere. Though, dration and anxiety. Psychological counseling characteristically hematidrosis means blood in can also help if a person with hermatidrosis has sweat, but basically blood is mixed with sweat depression and anxiety. like material somewhat than true sweat in this CASE REPORT disorder1. Our first case was a 27-year-old female The word “hemato folliculo hidrosis” was patient who reported to the department of ENT & suggested by Manonukul et al. because it seemed Head and Neck Surgery with the chief complaint along with sweat-like fluid and the blood exuded of recurrent bleeding from both ears for the last 2 via the follicular canals . Numerouscontributing 6-8 years (fig-1). She also used to have blood factors have been proposed by Holoubek; like tinged tears for which she had been thoroughly part of systemic disease, vicarious menstruation, investigated at eye department of a tertiary care too much exertion,psychogenic, psychogenic hospital but no cause could be found. She had no purpura, and mysterious causes. Acute anxiety co-morbid and was not on any medication. There and deep mental contemplation are the most was no previous history of heavy menstrual 3 frequent causes . Tshifularo M reported it as bleed, bleeding from any other siteor bleeding on under extreme physical or emotional stress this exposure to trivial trauma. Moreover there was may occur in religious (Jesus Christ prayer no family history ofany bleeding disorder. Her experience in Gethsemane) and non-religious symptoms used to aggravate during period of (soldier sweat blood before battle) conditions. emotional stress. The diagnosis of hemato hidrosis is made on Examination revealed an anxious looking the presence of bloody discharge through intact young lady who was vitally stable and with no skin without any obvious cause, observed and positive finding on general and systemic exami- Correspondence: Dr Tarique Ahmed Maka, Classified ENT nation. Examination of ears showed crusted Specialist, CMH Risalpur Pakistan (Email: [email protected]) blood in both external auditory meatuses without Received: 03 Jan 2019; revised received: 04 Jun 2019; accepted: 13 Jun 2019 any break in skin or integrity of tympanic 730 Hematohidrosis Pak Armed Forces Med J 2019; 69 (3): 730-32 membrane. There was no mass, ulceration orany sented with recurrent bleeding from nose and lesion apart from crusted blood, examination of ears. The bleeding used to be unprovoked, self- both ears was therefore essentially normal. Nose limiting and was not used to be associated with and throat exam did not reveal any abnormality. pain or any other symptom. Her blood compete picture, coagulation profile, Examination revealed crusted blood in autoimmune profile, hepatic & renal functions external auditory canal without an abnormality of ears. Crusted blood was also seen in nasal vestibule but nasal mucosa and skin were normal. The bleeding episodes were associated with periods of rage and stress. There was no history of heavy menstrual bleed, bleeding from any other site or bleeding on exposure to trivial trauma. There was no family history of any bleeding disorder. All her laboratory investi- gations failed to reveal an abnormality. She was Figure-1: Showing recurrent bleeding from both ears. diagnosed to be suffering from haematohiderosis. She and her husband were counselled about the disease and her treatment was modified in consultation to psychiatrist and propranolol was added. She was followed up for three months and was doing well, later she lost to follow up due to shifting of residence. DISCUSSION Figure-2: Showing under treatment of psychiatrist. Hematidrosis orhematohidrosis also known were all within normal limits. Lab examination of as blood sweat, is asporadic condition in which a crust from external auditory meatuses confirmed human sweats blood. This condition predo- it to be blood. minantly is reported in females. Blood generally oozes from the forehead, umbilicus, nails and On the basis of history, clinical exam and lab other skin surfaces. In adding, oozing from investigation, she was diagnosed to be suffering mucocutaneous surfaces causing bloodstained from haematohidrosis. She was started with tears, bleeding nose, bloodstained ear discharge tablet propranolol and tablet escitalopram. She and vicarious menstruation are common5. It has was counselled about the non-life threatening been proposed that acute fear and extreme strain diagnosis and was instructed to effectively cope can cause hematidrosis. The incidences may be with stressful conditions. She lost to follow-up till headed by intense headache and abdominal was hospitalized with gestational hypertension pain and are commonly self-limiting. In some and ENT opinion was seeked by gynaecologist. conditions, the secreted fluid is more dilute and Both the gynaecologist and patient were exp- look like to be blood-tinged, while others may lained about the benign nature of the condi-tion. have darker bright red secretions similar to The patient was advised to restart the medi- blood6. cation after termination of gestation. On solitary followup she was doing fine. Sympathetic activation is a suspected cause in at least some of the cases because the adminis- Our second case was a 34 years old female tration of a sympathetic blocker (such as pro- who was a known case of depression and was pranolol) may suppress further episodes over the under treatment of psychiatrist (fig-2). She pre- next few months7. 731 Hematohidrosis Pak Armed Forces Med J 2019; 69 (3): 730-32 Hematidrosis also results in the skin highlight the relationship between psychogenic becoming tender and friable. Though the amount causes and hematohidrosis12. of blood loss usually is minimal, its effect on CONCLUSION the body is weakness and mild to moderate Hematidrosis remains enigmatic due to its dehydration from the both blood and sweat loss infrequent occurrence. Hematidrosis is so uncom- and the severe anxiety8. mon that studies on it frequently focus on a Lab investigations such as blood complete single case. Multiple investigations propose that picture, platelets count, platelet aggregation test, tiny blood vessels that cause bloody sweat are coagulation profile, hepatic& renal functions and more probable to rupture under intense strain skin biopsy reveal no abnormalities and direct and anxiety. The stress can be physical, emotional light microscopy of fluid exhibits presence of or both. Even though stress likely plays a role, it normal red blood cells. Further studies also failed cannot fully clarify this phenomenon. Hemati- to show any vasculitis or skin appendages (i.e. drosis is not associated with or a symptom of any sweat glands, sebaceous glands and hair follicles) life-threatening medical conditions. The bleeding anomalies3,9. usually stops on its own, and even without Also, the condition remains one of gruesome treatment, symptoms may disappear over time. fascination, but of great psychological suffering CONFLICT OF INTEREST for the victim. Treatments offered for hema- This study has no conflict of interest to be tidrosis range from psychotherapy in the form declared by any authors. of counseling and constant reassurance, to beta- blockers, and even alternative therapies in one REFERENCES case. Remission was spontaneous in some 1. Shahid RK, Shahzad M, Nusrat R. Ghost spell or hema-tohidrosis. J Coll Physician Surg Pak 2013; 23(4): 293-94. patients, but occurred either partially or fully 2. Arakkal GK, Poojari S, Netha GN, Kumar BU. 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