AN INTERESTING CASE OF BLOODY SWEAT
(HEMATOHIDROSIS)
ABSTRACT
Hematohidrosis or hematidrosis is a rare disorder characterized by one or more attacks of spontaneous, selflimited, bloody sweating from the intact skin. In this literature, a case of a 9-year-old girl was presented
with recurrent self-limiting episodes of bloody sweating from the left upper arm upon exposure to extreme
stress and anxiety. The patient had no history of bleeding disorders, physical trauma, or drug intake. All
blood investigations of the patient were within the normal range. The outcome was favorable in this case
with pharmacotherapy (beta-blocker) and psychological support.
INDRODUCTION
Hematidrosis or hematohidrosis is a rare clinical condition in which blood is excreted with sweat on
exposure to the extreme physical or emotional stress.[1] The exact etiopathogenesis of this condition is not
clear. One hypothesis proposed for etiopathogenesis of hematohidrosis[2] was that multiple blood vessels
present in a net-like form around the sweat gland constrict on exposure to extreme anxiety. When the
anxiety passes out, the blood vessels dilate to the point of rupture. The blood gets into the sweat glands,
which will be pushed out it along with sweat to the surface, presenting as droplets of blood mixed with
sweat. Anxiety activates the sympathetic nervous system to invoke stress-fight reaction to severe degree as
to cause hemorrhage of the blood vessels supplying the sweat glands into the ducts of the sweat glands.[3]
Etiology can be systemic disorders (bleeding disorders), vicarious menstruation, excessive physical
exertion, and psychological stressors.[1] True hematohidrosis means the presence of underlying bleeding
disorders.[4] Treatment of the underlying cause helps in the remission. However, in the cases with systemic
etiology, psychological stressors act as a precipitating factor. There are case reports of bleeding from skin
(hematohidrosis), bleeding from eyes (hemolacria)[5] and ears (blood otorrhea) [6].
CASE REPORT
A 9-year-old girl was brought to the OPD with complaint of blood oozing from the left upper arm for past
1 month. First episode of bleeding happened 1 month before at the school following the incident when she
fought with her co student and was punished by her teacher. The teacher noticed bleeding from her left
upper arm. They gave first aid, informed to her mother and sent home. Since then, the bleeding occurred
about once or twice a week, which was spontaneous, lasted for about 3–5 min from left upper arm. Not
associated with pain. No history of bleeding from any other site, drug intake was present. No history of
bleeding disorder or any skin infection was found. Family milieu patient was fearful of her father who was
an alcoholic. He would scold her frequently, comparing her academic performances with her sibling. On
examination, the child was alert, oriented and communicates relevantly. Physical examination revealed
normal vital signs and average body built. On presentation, blood was oozing from the left arm, which was
wiped off with sterile gauze. No signs of any physical injury. No tenderness, no sinus, no regional
lymphadenopathy. BCG scar +. Written informed consent by the patient was obtained. The laboratory
results were normal, regarding platelets count (3.2lacs), activated partial thromboplastin time (33.9 s),
prothrombin time (12.7 s), and normal bleeding and clotting time. Microscopic examination of the discharge
fluid revealed RBCs and other components of blood. Parents were counselled about the child's condition.
Parents were taught about positive and negative reinforcement techniques and their advantages over
punishment. Child was taught relaxation exercises and pharmacotherapy was initiated treatment with
propranolol 10 mg twice daily. After 2 weeks of treatment, the bleeding episode gradually reduced in
frequency and drug continued. The child is under regular follow up.
DISCUSSION
Hematohidrosis also known as hematidrosis, hemidrosis, and hematofolliculohidrosis is a rare clinical
condition in which capillary blood vessels that feed the sweat glands rupture, causing bloody sweat; it
occurs under conditions of extreme physical or emotional stress.[1] There are a various theory that explain
the etiopathogenesis of hematohidrosis. The general consensus statement relates to the intensified
sympathetic activation due to extreme physical or emotional stress. The sympathetic flight-or-fight response
to intense stress leads to constriction of capillary vessels feeding sweat glands. When the anxiety subsides,
the blood vessels dilates to the point of rupture, leading to them passage of blood through the ducts of sweat
glands and presenting as the droplets of blood mixed with sweat on the intact skin surface in almost any
part of the body. [7,8] The term “hematofolliculohidrosis” was proposed as it appears along with sweat and
the blood pushes via follicular canals.[9]
Diagnosis of hematohidrosis can be made if the following criteria are met: (i) recurrent, spontaneous,
painless and self-limited oozing of bloody discharge from skin surface is witnessed and confirmed by health
care professionals, (ii) usual blood components are found on biochemistry studies of the bloody discharge,
and (iii) the site of bleeding is intact with no signs of abrasion, telangiectasia or purpura and after wiping
the area, there is no evidence of oozing. All of these three criteria must be met in order to rule out other
causes of bleeding like organic bleeding disorders, self-inflicted bleeding, factitious disorder by proxy, and
chromhidrosis.[10]
Histopathological examination of the affected by Zhang et al., revealed few intradermal bleeding and
obstructed capillaries in the affected area. No apparent abnormality was found in sweat glands, hair
follicles, and sebaceous glands.[3] Biopsy examination during asymptomatic period did not reveal any
blood-filled vascular spaces, intradermal bleeding or apparent abnormality in hair follicle, sebaceous, or
the sweat glands. Benzidine test can be used as important tool for diagnosis, where hemoglobin in blood
reacts with H2O2-liberating oxygen, which then reacts with reagent producing a green to blue colored
compound.[6] Treatment of this condition is not clear. There was one report of successful use of
propranolol.[8] In this case, the patient shown improvement to pharmacotherapy (propranolol) along with
psychotherapy.
CONCLUSION
Hematohidrosis should be considered as a miscellaneous differential diagnosis of bleeding in a patient with
normal physical examination and laboratory investigations. Establishing awareness among the physicians
play an important role in ensuring a non-judgmental and compassionate approach. Needed effective case
reporting after diagnosing hematohidrosis, to identify etiology and risk factors of this condition. And to
establish effective clinical management protocol.
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