Available Online at http://www.recentscientific.com International Journal of CODEN: IJRSFP (USA) Recent Scientific International Journal of Recent Scientific Research Research Vol. 12, Issue, 03 (C), pp. 41293-41296, March, 2021 ISSN: 0976-3031 DOI: 10.24327/IJRSR Research Article DIAGNOSIS & MANAGEMENT OF HEMATIDROSIS (SWEATING BLOOD) Elgharably Noura1 and Mohammed Al Abadie*2 1Medical School, Birmingham University, UK 2Department of Dermatology Royal Wolverhampton NHS Trust Wolverhampton WV10 0QP UK DOI: http://dx.doi.org/10.24327/ijrsr.2021.1203.5863 ARTICLE INFO ABSTRACT Hematidrosis is a rare condition where an individual excretes blood through the sweat gland pores. Article History: Bleeding is apparent on the intact skin in many parts of the body. The aetiology is unclear; however, th Received 10 December, 2020 theories suggest severe episodes of stress as well as other causative factors including systemic nd Received in revised form 2 diseases, vicarious menstruation, extreme exertion and psychogenic causes can stimulate the January, 2021 bleeding. It can also be seen in bleeding disorders. Reporting on several cases where sweat with th Accepted 26 February, 2021 human blood appeared from the forehead, face and body and patients had no underlying bleeding th Published online 28 March, 2021 orders, we will explore the unusual presentation of Hematidrosis and where atropine sulphate transdermal patch and propranolol have resulted in remission. Key Words: Hematidrosis, children, blood sweat Copyright © Elgharably Noura and Mohammed Al Abadie, 2021, this is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution and reproduction in any medium, provided the original work is properly cited. INTRODUCTION The secretion was collected and examined microscopically where many erythrocytes were observed. Peripheral smear of Hematidrosis is a condition where a human sweats blood(1). It (2) the secretion showed multiple red blood cells with gram is believed to be triggered by stress, strain or exertion .True positive cocci and bacilli, confirming the blood to be of human Hematidrosis occurs in bleeding disorders, however it may also (3) origin. The patient’s routine hemogram, blood counts, platelets, occur under extreme levels of stress . Near the sweat glands bleeding time, clotting time, active partial thrombin time, are blood vessels which can constrict and rupture when under prothrombin time, liver and renal function tests were all within the pressure of extreme physical or emotional stress. Here, as normal limits. the sweat glands produce sweat, the blood exudes to the surface, appearing as a red watery secretion(3). REVIEWING CURRENT LITERATURE Biswas et al report a case of Hematidrosis in a healthy 12-year- (4) old girl with no underlying disorders . She presented with a 2-year history of bleeding from the skin over the forehead, scalp, cheek, nose and trunk. The bleeding was episodic, occurring once or twice a day, and particularly in the morning. There was no history of anxiety or prior stressful events. The episodes began with a watery secretion which turned bright right within a few seconds, and in total lasted around 10-15 Fig 1 sweat admixed with blood from the right side of the face(4) minutes. There was no bleeding from any other sites, and nothing indicated ingestion of anticoagulants, dyes or other drugs. There was no history of medical or surgical illnesses, no familial pattern and menstruation cycles were normal. There were no abnormalities on both physical and systemic examinations and the skin over the forehead remained intact with no tenderness(4). *Corresponding author: Mohammed Al Abadie Department of Dermatology Royal Wolverhampton NHS Trust Wolverhampton WV10 0QP UK Elgharably Noura and Mohammed Al Abadie., Diagnosis & Management of Hematidrosis (Sweating Blood) In this case, the patient was treated with propranolol (10mg twice a day), and symptoms began to reduce within a week. Propranolol was continued twice a day for the next month and then decreased to 5mg twice a day for another month. In follow up, the patient reported complete remission of symptoms and episodes, except for one when she had run a race and had a small amount of blood sweat on her legs. Hence a suggestion for effective treatment are b-adrenoceptor antagonists. Jayaraman et al reported a case of a 10-year-old girl who had a 1-week history of bleeding from the intact skin of the scalp(9). (4) This initially began following a fight with a student in her Fig 2 sweat admixed with blood from the nose school despite no physical trauma occurring at the bleeding The patient was treated with an atropine transdermal patch over site. Following this incident, the bleeding was once or twice the sites involved and noted steady remission in severity and daily and lasted for 3-5 minutes with no associated pain. frequency of episodes. After 1 month of treatment, the patient The patient had no bleeding disorder, systemic disease, and stopped getting episodes(4). skin biopsy was normal. She had a 2-year history of bed In this case, no causative factor was identified. Some authors wetting at night which was more frequent during exam periods have suggested that severe mental anxiety activates the and when scolded by parents. The patient’s parents often would sympathetic nervous system to invoke a stress-fight reaction scold and punish her physically for her exam performance, and effective enough to cause haemorrhage of the vessels which the child expressed regret about coming home. Stress analysis supply the sweat glands into the ducts of the sweat was conducted via the Stress Questionnaire-Child/Adolescent glands(5).The pathology of Hematidrosis has also previously version, which highlighted the child was severely stressed. The been suggested to be distinctive vasculitis(6), however this case child was diagnosed with mixed anxiety and depressive used direct immunofluorescence study which showed no disorder, and initial treatment consisted of imipramine and abnormalities. Treatment of this condition was successful with clonazepam with a 1-week follow up(9). atropine sulphate transdermal patch, as the patient showed During a follow up interview of the patient, an episode of red complete remission. However other studies have suggested the secretions from her scalp was evident upon explanation that she success of propranolol(7). had been punished for her academic performance. Biochemical Wang et al have reported a case of a 13-year-old girl who examination of the secretion confirmed the substance to be experienced frequent bleeding episodes for over 3 years(7). human peripheral blood, with no other abnormalities Spontaneous bleeding from intact skin was witnessed by reported(9). Skin remained intact under the scalp, and the hospital staff on more than 20 occasions in hospital admissions, bleeding resolved within a minute. from the subungual area, palms, feet, thighs, and trunk. These This case was management with parental training and psycho episodes never occurred when sleeping at night and appeared education for the parents regarding the role of stress. Positive more frequently during times of emotional excitement. The and negative reinforcement techniques were encouraged over patient’s blood count, blood biochemistry, platelet aggregation, physical punishment, and the child was taught relaxation bleeding time, coagulation screening tests, coagulation factors techniques. The bleeding completely stopped after 4 months and von Willebrand factor were all in normal limits, excluding and follow up over the next year showed complete remission. any haemorrhagic disorders. She also did not have In this case, the child’s severe mental anxiety and fear about menorrhagia, and the episodes were unrelated to menses, her educational performance presented as spontaneous excluding vicarious menstruation. Blood components were bleeding, highlighting the role of stress management in treating confirmed to contain the same components as the peripheral Hematidrosis. Remission was achieved with pharmacotherapy, blood. However, histopathology showed normal sweat gland supportive psychotherapy and family education. structure without blood when biopsy was performed post bleeding from the affected skin on the arm. The blood Vigorous exercise and sustained heat exposure were reported to capillaries were not obstructed, but minor blood extravasation trigger an episode of Hematidrosis in a report by Carvalho et al was observed. They concluded that the blood was mixed with a of a 9-year-old female who bled around the lips(10). The episode sweat-like fluid rather than real sweat and inferred a was unrelated to menses, and general examinations and sympathetic nerve activation was responsible for this(8). laboratory findings were all normal. Medical staff witnessed three later episodes, and biopsy confirmed the secretion to be Recurrent bleeding episodes were often linked to extreme peripheral blood. In one episode the patient was pre-examined, emotional excitement or fear. In a separate report, Manonukul (5) then observed in a hot environment where the episode began. et al. administered lorazepam , an anxiolytic to a patient to Medical staff were with her prior, during, and after the episode reduce her anxiety. The patient’s bleeding was initially treated and ensured that no injury had occurred. The report details that with vitamin C, carbazochrome sodium sulphonate and the patient spontaneously improved in her condition(10). diazepam – a similar anxiolytic – however this did prove to be Shahgholi reported three patients who had Hematidrosis. This efficacious. Thus, a suggestion of the role of sympathetic nerve (11) activation was explored, and propranolol was given to limit included an 8-year-old boy and two girls – aged 9 and 11 . vascular resistance. The boy was referred due to spontaneous bleeding from nail beds of hands and feet. This occurred prior to exams, playing 41294 | P a g e International Journal of Recent Scientific Research Vol. 12, Issue, 03 (C), pp. 41293-41296, March, 2021 computer games and when parents did not satisfy his demands.