Haematohidrosis in a Young Boy Temporally Associated With Psychological Stress: A Case Report

Abstract

Haematohidrosis is an exceptionally rare and poorly understood clinical phenomenon characterized by the spontaneous excretion of blood through intact skin or natural orifices, with episodes often reported in association with extreme emotional or psychological stress. Owing to its rarity, the condition often poses significant diagnostic challenges and may be misinterpreted as a bleeding disorder, self-inflicted injury, or factitious illness. We report the case of an 11-year-old boy who presented with a 1-month history of recurrent, painless, self-limiting episodes of bleeding from the eyes, nose, and ears. These episodes were temporally associated with periods of academic and parental stress. Comprehensive hematological, biochemical, and radiological investigations, including coagulation studies and von Willebrand factor assays, were within normal limits, effectively excluding systemic or inherited bleeding disorders. Cytological examination and a positive benzidine test confirmed the presence of blood in the secretions. A temporal association between psychosocial stressors and symptom onset was observed. The patient was managed with propranolol to attenuate sympathetic hyperactivity and cognitive behavioral therapy aimed at stress management and coping strategies. This case highlights the importance of recognizing haematohidrosis as a rare clinical condition in which psychosocial factors may play a contributory role, and emphasizes the role of multidisciplinary management to achieve favorable outcomes.

Introduction

Haematohidrosis, also referred to as hematidrosis or “bloody sweat,” is a rare clinical entity characterized by the spontaneous exudation of blood-tinged fluid through intact skin, sweat glands, or natural orifices.^1,2 Fewer than 50 cases have been reported in the literature, with a notable predominance among children and adolescents, particularly in Asian populations.^2,3 The condition is frequently associated with episodes of extreme emotional stress, fear, or psychological trauma. ³ However, the current understanding of haematohidrosis remains limited, with most evidence derived from isolated case reports rather than systematic studies, and the exact etiopathogenesis remains unclear and largely hypothetical.^2,3 Due to its dramatic presentation, haematohidrosis often leads to extensive investigations and anxiety for patients and caregivers.^3,4 Early recognition is essential to avoid unnecessary interventions. We present a rare case of stress-induced haematohidrosis in a pre-adolescent boy, successfully managed with pharmacological and psychological interventions.

Case Presentation

A 11-year-old boy was brought by his parents with complaints of recurrent, spontaneous episodes of bleeding from the eyes, nose, and ears over a period of 1 month (Figures 1 and 2). The bleeding was painless, unprovoked, and self-limiting, resolving spontaneously within minutes. The episodes were consistently precipitated by situations involving academic stress, peer pressure, or parental expectations regarding academic performance. There was no history of trauma, infection, fever, medication use, epistaxis disorders, or similar episodes in the past. There was no family history of bleeding diathesis.

Vital signs were stable and within age-appropriate limits. General physical and systemic examination revealed no abnormalities. During observation, active bleeding from the eyes and ears was noted. Further clinical evaluation of the ocular and otorhinolaryngological regions was performed to exclude local causes of bleeding. Examination revealed no evidence of conjunctival lesions, lacrimal duct abnormalities, nasal mucosal pathology, or trauma. Otoscopic examination of the external auditory canal and tympanic membrane was normal. These findings reduced the likelihood of structural causes of bleeding. Dermatological examination showed intact skin. A comprehensive diagnostic workup was performed to exclude systemic causes:

• Complete blood count, liver and renal function tests, random blood sugar: within normal limits (Table 1).

• Coagulation profile (PT, aPTT, fibrinogen): normal

• Von Willebrand factor antigen: normal

• Chest radiograph and urinalysis: unremarkable

• Cytological examination of secretions: numerous erythrocytes with occasional leukocytes

• Benzidine test: positive, confirming the presence of blood

Table 1.

Laboratory Investigations.

Investigation	Result	Reference range
Hemoglobin	11.3 g/dL	11-15 g/dL
Total leukocyte count	6900/mm3	4000-11 000
Platelet count	2.8 × 105/mm3	150-450 × 103/µL
Prothrombin time (PT)	12.1 s	11-14 s
Activated partial thromboplastin time (aPTT)	37 s	25-40 s
Fibrinogen	3.5 g/L	2-4 g/L
Von Willebrand factor antigen	133 IU/dL	50-150 IU/dL
Serum creatinine	0.4 mg/dL	0.3-0.7 mg/dL

Psychological assessment was performed by a psychiatrist. The evaluation focused on identifying emotional triggers, behavioral responses, and potential psychosocial stressors contributing to the episodes. The child reported significant anxiety related to academic expectations and perceived parental pressure to perform well in school. No evidence of factitious disorder, malingering, or self-inflicted injury was identified. Psychological evaluation was conducted by a consultant psychiatrist within 1 week of presentation, across 2 clinical sessions of approximately 30 minutes each. The assessment was unstructured and clinically oriented, focusing on history-taking, behavioral observation, and identification of psychosocial stressors. Clinical impressions were derived from caregiver interviews, child self-report, and behavioral observations during consultations. Although no standardized or quantitative psychometric tools were administered, the evaluation suggested emotional distress temporally associated with academic and familial stressors. The assessment was conducted outside of active bleeding episodes.

The patient subsequently underwent cognitive behavioral therapy (CBT) delivered by a licensed clinical psychologist. The intervention consisted of structured individual sessions conducted weekly over 4 weeks, each lasting approximately 45 minutes. Therapy focused on stress identification, emotional regulation, cognitive restructuring, relaxation techniques, and development of adaptive coping strategies for academic pressure. No formal DSM-5 psychiatric diagnosis was established, and the intervention was guided by a stress-related clinical formulation rather than a categorical diagnosis. Parents were actively involved in the counseling process and received psychoeducation regarding stress management, supportive communication, and reduction of academic pressure at home. The patient was also initiated on oral propranolol (0.5 mg/kg/day) divided into 2 doses, administered under clinical supervision. The medication was prescribed to attenuate sympathetic hyperactivity and stabilize vascular responses associated with stress. Clinical improvement was observed within 2 weeks of initiating therapy, with a marked reduction in the frequency of bleeding episodes. At 4-week follow-up, only occasional mild episodes were reported, and by 3 months of follow-up, the patient remained asymptomatic during routine activities.

Figure 1.

Spontaneous periocular bleeding in a child with haematohidrosis.

Figure 2.

Recurrent spontaneous bleeding from multiple facial sites (external auditory canal, periocular region, and nostrils).

Discussion

Hematohidrosis is a rare and enigmatic clinical phenomenon characterized by recurrent, spontaneous, painless, and self-limiting episodes of blood-stained secretion through intact skin or mucosal surfaces.^1,4 Since its first formal descriptions, fewer than 50 cases have been reported worldwide, making it an uncommon but striking diagnostic entity.^5,6 The condition most frequently involves the face, particularly the periocular region, ears, and nose, although bleeding from other sites such as the trunk and extremities has also been described.^{2 -6} Despite increasing recognition, the exact etiopathogenesis of hematohidrosis remains incompletely understood. Multiple contributory factors have been proposed, including systemic illnesses, vicarious menstruation, excessive physical exertion, psychogenic stress, and idiopathic causes.^4,5 Among these, psychological stress has emerged as the most consistently reported precipitating factor, particularly in pediatric and adolescent populations.^{6 -8} Importantly, this association is observational and does not establish causality. The lack of standardized psychological assessment and the presence of idiopathic cases suggest that multiple mechanisms may be involved.^2,5

The most widely accepted pathophysiological hypothesis implicates acute sympathetic nervous system hyperactivation during periods of intense emotional distress.^9,10 Nevertheless, this mechanism remains theoretical, and no definitive physiological model has been consistently validated across reported cases. Extreme stress is thought to induce transient vasoconstriction of the dermal capillary plexus surrounding sweat glands, followed by sudden vasodilation and increased intravascular pressure.^9,10 This abrupt hemodynamic shift may lead to rupture of fragile periductal capillaries, allowing red blood cells to extravasate into sweat ducts and be expelled onto the skin surface as blood-tinged sweat.^4,5 An alternative theory proposes the presence of transient dermal vascular spaces or stromal defects that communicate with deeper vascular channels. These spaces may temporarily engorge under stress and collapse thereafter without leaving permanent structural damage, accounting for the episodic and self-limiting nature of the condition.^{8 -10}

Histopathological findings in hematohidrosis are variable and often non-specific. Biopsies performed during active episodes have occasionally demonstrated dilated dermal capillaries, erythrocyte extravasation, or mild vasculitic changes, although many specimens appear normal.^4,5 Early biopsy during an active episode has therefore been recommended when feasible to enhance diagnostic yield.^3,5 Laboratory confirmation of the haemorrhagic nature of the discharge is essential. The benzidine test, which detects hemoglobin through an oxidative color reaction, and the hemochromogen test, which confirms the human origin of blood by identifying pyridine–hemoglobin crystals, have been traditionally used for this purpose.^{3 -5}

Diagnosis of hematohidrosis is primarily clinical and remains one of exclusion. Proposed diagnostic criteria include^7,10:

• Recurrent, spontaneous, painless bleeding episodes witnessed by healthcare professionals

• Biochemical confirmation of blood components in the secretions

• Intact skin or mucosa at the bleeding site with no residual lesions after wiping.

• Strict adherence to these criteria is critical to exclude important differentials such as bleeding disorders, self-inflicted injury, factitious disorder, and chromhidrosis.

Important differential diagnoses considered in this case included haemolacria, local mucosal pathology, trauma, chromhidrosis, bleeding disorders, and factitious disorder.^5,7 These conditions were systematically excluded through normal hematological investigations, absence of local lesions on clinical examination, lack of evidence of self-inflicted injury, and laboratory confirmation of blood in the secretions. The temporal association with psychological stress further supported a stress-related bleeding phenomenon. Epidemiological reviews suggest a female predominance and a median age of presentation around early adolescence. A review of 25 reported cases demonstrated that approximately 84% occurred in females, with most cases originating from Asia, particularly India and Pakistan. Facial involvement and psychological stress as a trigger were common features across reported cases. ⁵ There are no standardized treatment guidelines for hematohidrosis. However, beta-blockers, anxiolytics, and psychological interventions have been most frequently employed.^6,7,9 Beta-blockers such as propranolol are believed to be effective by attenuating sympathetic overactivity and stabilizing vascular tone, while psychotherapy, particularly cognitive behavioral therapy, addresses underlying emotional triggers.^9,10 Most reported cases, including the present one, demonstrate favorable outcomes with this combined approach.^2,5,6

This case report has several limitations. First, psychological assessment was based on unstructured clinical evaluation without the use of standardized or validated psychometric instruments, limiting objective quantification of stress or psychopathology. Second, the temporal association between stressors and bleeding episodes does not establish causality, and it remains possible that the patient did not experience clinically significant psychological distress. Third, advanced ophthalmologic and otorhinolaryngological investigations (slit-lamp examination, nasal endoscopy) were not performed. Finally, alternative explanations including physiological, dermatological, hematological, or idiopathic mechanisms cannot be definitively excluded. As a single case report, generalizability is inherently limited.

Conclusion

Haematohidrosis is a rare clinical entity that should be considered in children presenting with recurrent, painless bleeding from intact skin or natural orifices after exclusion of organic causes. In this case, a temporal association with psychosocial stressors was observed. A multidisciplinary approach incorporating careful clinical evaluation, symptomatic management, and supportive psychological interventions may be beneficial and can lead to favorable clinical outcomes. Further studies using structured psychological and physiological assessments are required to better understand the underlying mechanisms of this condition.