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International Journal of Dermatology 2008, 47, 1058–1059 © 2008 The International Society of Dermatology 

1058

Abstract

The authors report the case of a 9 year-old female who had bleeding episodes around the

mouth after strenuous exercise or prolonged exposure to heat. Characteristically, bleeding

occurred right after sweat drops started appearing on the surface of the skin around the mouth.

The bleeding episodes ceased spontaneously.

BlackwellPublishingLtdOxford,UKIJDInternationalJournalofDermatology0011-90591365-4632©2008The InternationalSocietyofDermatologyXXX

Case reportHematidrosisdaSilva Carvalho etal.Dermatologicsurgery

Hematidrosis: a case report and review of the literature

 

Ana Carolina da Silva Carvalho, MD

 

, Jackson Machado-Pinto, PhD

 

, Gustavo CarneiroNogueira, MD

 

, Luiz Maurício Costa Almeida, MD

 

, and Maurício Buzelin Nunes, MD, PhD, MSc

 

From the Dermatology and Pathology

Departments, Santa Casa de Belo Horizonte,

Brazil

 

Correspondence

 

Jackson Machado-Pinto, PhD

Av. Francisco Sales 1463/1207

Santa Efigênia

Belo Horizonte-MG

Brazil CEP: 30150-221

E-mail: jackpin@gold.com.br

 

Case Report

 

A 13-year-old girl reported the onset, in November 2004, of 

bleeding surrounding the lips during physical exertion or an

increase in room temperature, which ceased spontaneously.

The episodes were not related to menses, ruling out cutaneous

endometriosis. General clinical examination and all laboratory

evaluations were normal. Three episodes where witnessed by

medical staff. In one episode, 25 physicians were present and

the whole procedure was registered on a film. Initially, thepatient was examined and no wounds were found. She was

then observed in a favorable environment (hot weather). In

about 30 min, a red secretion was observed around the upper

lip (Fig. 1). Medical staff were with her at all times to ensure

that no previous injury had occurred. A smear of the upper lip

secretion was carried out and a biopsy was performed. The

secretion revealed the same components as found in peripheral

blood. Histologic analysis showed a normal epidermis and a

dermis with preserved pilosebaceous annexes and eccrine

sweat glands (Fig. 2). There were small, congested, periglan-

dular blood capillaries, some in close contact, without red

blood cell extravasation (Fig. 3). The patient evolved withspontaneous improvement of the condition.

 

Discussion

 

Hematidrosis, the excretion of “bloodsweat”, is a rare dis-

ease, with only a few cases reported to date. The case reported

here occurred spontaneously. Hematidrosis can be located in

any part of the body, and there may be associated pain or

local erythema. As isolated phenomena, bleeding episodes do

not affect the patient’s general state of health.

 

1

 

In a recent

review of hematidrosis, 66 cases were evaluated and classified

according to causative factors: systemic disease, vicarious

menstruation, physical exertion, psychogenic, and unknown.

 

1

 

Cases related to systemic diseases are caused mainly by

Figure 1 The patient during a bleeding episode

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© 2008 The International Society of Dermatology International Journal of Dermatology  

 

2008, 47

 

, 1058–1059

 

1059

 

da Silva Carvalho et al. Hematidrosis

 

Case report

 

scurvy, epilepsy, and malaria. Vicarious menstruation is a

designation applied to cases of extragenital hemorrhage at

periodic intervals, corresponding to the menstrual cycle,

mostly related to endometriosis. The most frequent location

is the nasal mucosa, as epistaxis.

 

1,2

 

Cases related to excessive

physical exertion occur with the performance of certain

strenuous exercises. Psychogenic cases can be divided into

three categories: a single episode, recurrent episodes, and stig-

matization. Blood sweating as a single bleeding occurrence

generally takes place during an acute episode of fear of death

or severe body injury. Recurrent episodes are a consequence

of emotional excitement and hypnosis.

 

1

 

‘Stigmatization’

historically refers to the transfer of the wounds of Jesus Christto believers by fervent praying, and occurs as scars, pain,

wounds, and bleeding through intact skin at regular inter-

vals.

 

1,3,4

 

A few cases have unknown origins. Diagnosis is made

by the finding of peripheral blood cell exudate of intact skin,

witnessed and collected by a physician or other reliable

medical personnel.

 

1,5

 

It should be differentiated from chroma-

tidrosis and pseudochromatidrosis.

 

1

 

It is important to rule

out bleeding from self-injury.

 

6

 

Little is known of the histo-

pathology. Some studies have shown that the blood enters a

duct next to the exit point on the skin surface, which indicates

escape by rupture or diapedesis of superficial capillaries, and

leakage through the epidermis surrounding ducts and sweat

glands.

 

1

 

Another recent study showed intradermal bleeding

and emphraxised capillaries, with no abnormalities in the

sweat glands, hair follicles, and sebaceous glands, suggesting

that hematidrosis is a distinctive vasculitis.

 

5

 

It is probable that

there may be a minor communication between a small blood

vessel and sweat gland.

Because it is a rare disease and its histopathology is unknown,

any suspected case of hematidrosis should be investigated

both clinically and histologically.

 

References

 

1 Holoubek JE, Holoubek AB. Blood, sweat and fear. J Med 

 

1996; 27

 

: 115–133.

2 Jones HW, Wentz AC, Barnett LS, eds. Novak’s Textbook of

Gynecology

 

, 11th edn. Baltimore, MD: Williams & Wilkins,

1988: 259.

3 Lifschutz JE. Hysterical stigmatization. Am J Psychiatry

 

1957; 114

 

: 527–531.

4 Klauder JV. Stigmatization. Arch Dermatol 

 

1938;

37

 

: 650–659.

5 Zhang FK, Zheng YL, Liu JH, et al 

 

. Clinical and laboratory

study of a case of hematidrosis.Zhonghua Xue Ye Xue Za Zhi

 

2004; 25

 

: 147–150.

6 Allen AC. Disorders of cutaneous appendages. In: Allen AC,

ed. The Skin: A Clinicopathological Treatise

 

, 2nd edn. New

York: Grune & Stratton, 1967: 747.

Figure 2 Histopathology of the skin in the bleeding area

(hematoxylin and eosin, ×40)

Figure 3 Congested capillary in close contact to an eccrine gland

(hematoxylin and eosin, ×400)