Introduction
Hematohidrosis, with a synonym of hematidrosis, is an exceptionally rare condition in which blood is sometimes excreted through the skin, in particular, through the eccrine sweat glands (1). It is considered that the pathogenesis of hematohidrosis stems from an increased activity of the sympathetic nervous system towards extreme vasospasm and subsequent rupture of the capillary blood vessels surrounding the sweat glands (2). Its induction is most probably through acute physical or emotional stress, though other possible contributory factors are systemic infections, coagulopathies, and autonomic dysfunction (3). Due to its rare and underreported nature, epidemiological information concerning hematohidrosis has been sparse (4). Case reports would, however, cite that predominantly children and young adults have been most affected, with females at a higher incidence (5). A review of 42 cases found nearly 85% of the patients reported to be below 20 years, with stress being the primary triggering factor (6). Hematohidrosis can, however, present as isolated episodes of bleeding but has been associated with other such conditions as platelet disorders, systemic vasculitis, or infectious diseases like dengue (7). Hemolacria, or bloody tears, is also rare and may result from trauma, infections, tumors of the lacrimal gland, or systemic bleeding disorders; thus, most often it is idiopathic hemolacria, meaning an underlying further pathology could not be found (8). This becomes more complicated by the presence of epistaxis, as its presence would indicate either primary hematological disorders, vascular anomalies, or inflammatory conditions, such as allergic rhinitis or Wegener’s granulomatosis (9).
Hematohidrosis is ill-defined from a pathophysiological standpoint. The most current theorization of this condition holds that excessive sympathetic activation produces instability among the system of microvasculature that leads to the leakage of blood through eccrine sweat glands (10). The histopathological examinations of the skin occasionally demonstrate dilated dermal capillaries with milder perivascular inflammation (11). Yet it occurs that, because of the absence of a systemic coagulopathy in the majority of cases, its actual etiology is equally obscure (12). Some, however, did state that psychological stress incited changes in hormones—especially involving catecholamines—which is believed to cause the weakened structure of the blood vessels and increased permeability (13). Despite its dramatic presentations, hematohidrosis is self-limiting, although the episodes may recur after a few months or years. The management is rather inconsistent, spanning from beta blockers (propranolol) to other alternative therapies, such as homeopathy or Ayurveda. However, there is no one set treatment protocol for the limited reported cases. The coincidence of hematohidrosis, hemolacria, and epistaxis in a child is very rare, and few documented cases can be found in literature. This report aims to enhance the information available on this condition, its diagnosis, laboratory investigations, and treatment approach. In addition, it intends to address poor awareness in its pathophysiology and management strategies.
Methodology
The case report entails retrospective documentation of an 11-year-old female patient presenting with simultaneous hematohidrosis, hemolacria, and epistaxis. The study was deemed ethical according to the Code of Ethics of the World Medical Association (Declaration of Helsinki) and approved by the Institute Ethical Committee (Ethics Approval number). Informed consent for publication was obtained from the guardians of the patient. Case details were collected through a clinical interview and physical examination. Further standard investigations were carried out, which included hematological tests (complete blood count, coagulation profile, and peripheral smear), biochemical analysis (liver function tests), and imaging studies (low-dose brain computed tomography [CT] scan) to rule out systemic, vascular, or hematological causes. Based on the slit-lamp examination, an eye specialist did the evaluation to see if ocular involvement existed. All laboratory and imaging findings returned normal results, which made the case even more interesting. This report reveals the clinical presentation, the diagnostic process, and a differential diagnosis of this rare condition while commenting on the possible etiological mechanisms and the literature on hematohidrosis. No treatment was instituted, and no follow-up was done, since this case report is not a clinical report but rather a description and academic discussion of a rare phenomenon.
Results
The case profile of our patient, an 11-year-old girl, admitted to the hospital in the last 1 year with recurrent episodes of epistaxis, hematohidrosis, and hemolacria. The episodes occurred spontaneously, varying in time interval, and were free of any prior trauma, systemic illness, or hematological disorders. On examination, blood-stained sweat droplets were noted in her ears, and, with gentle manipulations of the eyelids, blood-tinged tears were seen (Figures 1 and 2). Nutritionally well and maintaining stable vital signs, her systemic examination was clear; nonetheless, a whole battery of supported laboratory workups was conducted to rule out systemic bleeding disorders. The results (Table 1) showed that all of the hematological and coagulation parameters were within the normal range, yielding no evidence of anemia, thrombocytopenia, or coagulopathy. The studies for factor assays and plasma fibrinogen levels were also normal. Liver function tests showed no hepatic dysfunction contributing to bleeding tendencies. A low-dose CT scan of the brain was carried out to rule out any possible sources of intracranial pathology, vascular malformations, and structural malformations. Imaging findings were free of infection, hemorrhage, or mass lesions. Mild ethmoid sinusitis was noted, and the mastoid air cells were hyperpneumatized, as well as had high-riding jugular bulbs. On a peripheral smear, erythrocyte morphology was confirmed as normal with only slight anisocytosis and lymphocytosis. An ophthalmological examination and slit-lamp tests ruled out any ocular pathology responsible for hemolacria (Table 2). The absence of systemic abnormalities together with normal laboratory, imaging, and biochemistry results left this case a unique and diagnostic nightmare. Despite such dramatic clinical presentation, the underlying cause remains elusive, thus pointing to the need for further research on the etiology and mechanisms of hematohidrosis, hemolacria, and epistaxis.
Figure 1. The image illustrates blood-stained perspiration droplets on the patient’s forehead and around the eyes, as well as blood-tinged tears that were observed when the eyelids were gently moved. This was recorded during an episode of hemolacria and hematohidrosis.
Figure 2. During an episode of hematohidrosis, the picture shows blood-stained sweat droplets coming from the patient’s ears.
Table 1. Laboratory and diagnostic findings.
Table 2. Imaging and ophthalmological findings.
Discussions
The present case fits into the general pattern; thus, the patient was an 11-year-old girl free of hereditary history or any medical history of bleeding disorders. Similar to previous reports, hematological, coagulation, and imaging studies were within normal limits, adding to the mystery of this condition. The absence of defined systemic abnormalities indicates the need to search for additional research to find reliable diagnostic markers (14). Whereas there does not exist a standard treatment protocol, many management strategies have been explored. In some reported cases, beta-blockers like propranolol have reduced sympathetic nervous system hyperactivity, though treatment responses to these agents remain inconsistent (15). In other reports, integrative approaches combining vitamin C supplementation with Ayurvedic formulations and homeopathic remedies purportedly reduced bleeding episodes in some patients (16). One case report noted a 4-year period free of symptoms in a 21-year-old male treated with Ayurvedic medicine and counseling, suggesting a role for stress management methods in controlling symptoms (17). Another case provided evidence of an effective homeopathic treatment of a 9-year-old boy with a constitutional remedy that gave lasting symptomatic relief for a 3-year follow-up period (18). Nevertheless, these observations are only anecdotal and have received very scant clinical confirmation; indeed, they require that controlled studies be conducted to ascertain their therapeutic influence.
Hematohidrosis tends to get more attention with varying degrees of dramatic presentation. However, in the absence of standardized diagnostic criteria and guidelines, treatment poses considerable stiffness to the reluctance of clinicians (16). The extensive workup and misdiagnosis could impose psychological strain on the patient and a financial toll on patients and their families. In this light, there is a need for a very strong campaign directed toward the underpinnings of timely diagnosis and appropriate treatment. The strength of the case report is found in the focused clinical keying into identifying these contributions to the ever-increasing catalog of literature on hematohidrosis, hemolacria, and epistaxis. Findings are further supportive of the theory that these conditions occur in the absence of systemic abnormalities, thus stressing the importance of non-invasive methods for diagnostics. Suffice it to say, the case report is limited, as it fails to include any longitudinal follow-up period aimed at charting symptom patterns over time, nor were psychological or any tests on autonomic functions conducted.
Conclusion
Upon clarifying the mechanisms behind hematohidrosis and identifying biomarkers for early diagnosis, there will be a need to evaluate the role of stress-related neurohormonal pathways and conduct randomized trials to assess treatment efficacy. Finally, it may help open pathways for interdisciplinary research between dermatology, neurology, and psychoneuroimmunology to help delineate the mechanism(s) involved in hematohidrosis and improve clinical outcomes for affected patients. This case highlights the diagnostic complexity of hematohidrosis, hemolacria, and epistaxis and demonstrates the need for further research and awareness in the medical community.
Abbreviations
APTT, Activated Partial Thromboplastin Time; BT, Bleeding Time; CBC, Complete Blood Count; CT, Clotting Time/Computed Tomography (context-specific); INR, International Normalized Ratio; LFT, Liver Function Test; MCH, Mean Corpuscular Hemoglobin; MCHC, Mean Corpuscular Hemoglobin Concentration; MCV, Mean Corpuscular Volume; MPV, Mean Platelet Volume; PT, Prothrombin Time; RDW-CV, Red Cell Distribution Width-Coefficient of Variation; SGOT (AST), Serum Glutamic Oxaloacetic Transaminase (Aspartate Aminotransferase); SGPT (ALT), Serum Glutamic Pyruvic Transaminase (Alanine Aminotransferase)
Author contributions
V.A.: Conceptualization, Data collection, Clinical assessment, Literature review, Writing – original draft. G.S.: Data analysis, Interpretation of laboratory and imaging findings, Literature review, Writing – review and editing. G.G.: Data interpretation, Literature review, Writing – review and editing.
Funding
No external funding was received for the preparation of this case report.
Acknowledgments
The authors thank Vinayaka Mission’s Homeopathic Medical College & Hospital, the patient and her family, and the clinical, radiology, and laboratory teams for their support and cooperation in this case report.
Conflict of interest
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
References
1. Anyfantakis D, Tsoucalas G, Karelis A, Papazoglou N, Spandidos DA, Krasagakis K, et al. Diapedesis leading to hematidrosis due to abrupt emotional suffering (Review). Exp Ther Med. (2024) 28(6):1–15.
2. Biswas S, Surana T, De A, Nag F. A curious case of sweating blood. Indian J Dermatol. (2013) 58(6):478–80.
3. Chakraborty RK, Burns B. Systemic inflammatory response syndrome. In: StatPearls. Treasure Island (FL): StatPearls Publishing (2025). Available online at: http://www.ncbi.nlm.nih.gov/books/NBK547669/
5. Octavius GS, Meliani F, Heriyanto RS, Yanto TA. Systematic review of hematidrosis: time for clinicians to recognize this entity. World J Dermatol. (2023) 11(2):7–29.
6. Kluger N. Hematidrosis (bloody sweat): a review of the recent literature (1996-2016). Acta Dermatovenerol Alp Pannonica Adriat. (2018) 27(2):85–90.
7. Rossio I, Gonçalves A. Haematidrosis: the rare phenomenon of sweating blood. Eur J Case Rep Int Med. (2014). Available online at: https://www.ejcrim.com/index.php/EJCRIM/article/view/144
8. Drake AE, Packer CD. Epistaxis complicated by hemolacria: a case report. Clin Med Res. (2020) 18(2–3):99–101.
9. Rout P, Garlapati P, Qurie A. Granulomatosis with polyangiitis. In: StatPearls. Treasure Island (FL): StatPearls Publishing (2025). Available online at: http://www.ncbi.nlm.nih.gov/books/NBK557827/
10. Jerajani HR, Jaju B, Phiske MM, Lade N. Hematohidrosis – a rare clinical phenomenon. Indian J Dermatol. (2009) 54(3):290–2.
11. Patel RM, Mahajan S. Hematohidrosis: a rare clinical entity. Indian Dermatol Online J. (2010) 1:30–2.
12. Samuels JM, Moore HB, Moore EE. Coagulopathy in severe sepsis: interconnectivity of coagulation and the immune system. Surg Infect (Larchmt). (2018) 19(2):208–15.
13. Khalil B, Rosani A, Warrington SJ. Physiology, catecholamines. In: StatPearls. Treasure Island (FL): StatPearls Publishing (2025). Available online at: http://www.ncbi.nlm.nih.gov/books/NBK507716/
14. Badry MS, Elbadry MI, Ragab ARAM, Ahmed ME. Hematohidrosis: reports and update of clinically mysterious phenomenon. Indian J Otol. (2020) 26(2):99.
15. 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(6):e7337.
16. Chen Y, Wang Y, Dong X. Genetic analysis and treatment strategy for hematohidrosis in a child. Int J Dermatol. (2024) 63(1):e10–2.
17. Beena KG. Ayurvedic management of haematohidrosis - a case report. Int Res J Ayurveda Yoga. (2022) 5(7):118–22.
18. Madsen R. Homeopathy and haematidrosis—a case of Calcarea phosphorica. Homoeopath Links. (2023) 36(3):219–23.
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