Posted by drmarkgriffiths
“A girl has become a holy shrine in India where worshippers watch her cry blood instead of tears. Doctors in Patna, north-east India, have been stumped by Rashida Khatoon’s condition, which causes her to shed tears of blood several times a day. But local Hindu holy men have declared her a miracle. And followers now flock to her home, showering her and her family with gifts as holy offerings” (The Sun, April 7, 2009)
The case of Rashida Khatoon caused headlines around the world a few years ago and was for many people the first time they had come across haemolacria (that literally means “bloody tears”). The condition of haemolacria has been documented a number of times on the medical literature and is a physical condition that causes individuals to cry tears that (in part) consist of blood. Haemolacria can be a symptom of various medical conditions including the relatively minor (such as eye inflammation and bacterial conjunctivitis) to the very serious (such as tuberculosis or a tumour in the tear ducts). However, in Khatoon’s case, there didn’t seem to be any underlying pathology to explain her bloody tears. Arguably the most well known person suffering from haemolacria is another Indian, Twinkle Dwivedi who has appeared on both the Body Shock television series (The Girl Who Cries Blood) and a television documentary on the National Geographic channel. However, the Wikipedia entry on haemolacria casts some doubts on her condition and notes:
“In lack of a medical explanation for her condition, possible religious explanations have been posed. She could have an unknown disease that only she appears to be suffering from, but more skeptical views hypothesize that the case might be explained by the so called Munchausen syndrome by proxy, meaning her mother, seemingly the only one to witness her bleeding actually starting, is fabricating the story and somehow inducing the effect on the girl”.
Given most of the published papers on haemolacria are case studies, one of the largest studies was published in 1991 by Dr. E. Ottovay and Dr. M. Norn in the journal Acta Ophthalmologica. In their study, 125 healthy individuals were specifically examined for blood in their tears. The authors reported that haemolacria was found in 18% of fertile women (most often while menstruating), 7% of pregnant women, none of the menopausal women (n=7), and 8% of men. The authors claimed that haemolacria among fertile women appears to be induced by hormones, whereas haemolacria among men is due to local factors (bacterial conjunctivitis, environmental damage, injuries, etc.).
In 2003, Dr. M. Wiese published a case study of a 56-year old women with short lasting haemolacria in the British Journal of Ophthalmology. She turned up to the hospital’s emergency department following two hours of continuous bleeding from her right nostril. She tried to stop her nose bleeding by pinching her nose but then experienced bleeding from her right eye and ear. Dr. Wise reported that”
“Its anatomical basis lies in the intimate connection of nose and eye via the lacrimal apparatus. An increase in pressure within the nasal cavity during epistaxis [nosebleeds] – for example, by pinching or blowing the nose, can cause retrograde flow of blood through the system and thus lead to bloody tears emerging from the ipsilateral eye. As our patient had longstanding perforation of both tympanic membranes, the blood in her nose was also able to travel retrograde via the auditory tube and middle ear into the external auditory canal. This led to the additional bleeding from the right ear”.
A similar case was reported by Dr. Stephan Weiser in a 2012 issue of the Emergency Medicine Journal. Weiser reported the case of a 73-year old man with arterial hypertension (i.e., high blood pressure) who while trying to stem the flow of blood from a nosebleed, pinched his nose, stopped the nosebleed but then started bleeding from his eyes. A different cause of haemolacria was published in 2010 by Dr. K. Mukkamala and his colleagues in the journal Retina. They reported haemolacria being a possible consequence of scleral buckle (SB) infection. SBs are used to help repair detached retinas and Mukkamala’s paper reported three patients (two males and one female) all of who had been crying bloody tears following the placement of an SB.
Many of the published case studies appear to be young girls. In 1987, Dr. B. Ahluwalia and his colleagues reported the case of a 15-year old girl with haemolacria in the Indian Journal of Ophthalmology. That may have been due to psychological (rather than physiological) causes. The first time the girl’s bloody tears were observed was by her parents when she was revising for her exams and in deep concentration reading her books. Her haemolacria was accompanied by giddiness and a headache but her eyesight was unaffected. It was on the third occasion of crying blood that her parents sought medical attention for their daughter. At the time of publishing their case study, the authors noted that she had had a total of 11 attacks (and that there was no relationship with her menstrual cycle). Physical tests revealed no abnormalities although the girl’s consulting psychiatrist reported that she had ‘hysterical traits’. The authors concluded that:
“In the present case of bloody tears we could not detect any organic cause for haemolacria after complete local and systemic examination and through investigations. The presence of hysterical traits as confirmed by the consulting psychiatrist led us to label hysteria as a possible case’ of bloody tears in this case. [Other authors have] also reported cases of haemolacria in patients of hysteria but the mechanism of production of bloody tears in these patients remain obscure, so far”.
Similarly, in 1999, a Brazilian team (led by Dr. T. Freitas) reported the case study of a young female with haemolacria in the journal Arquivos Brasileiros de Oftalmologia. They also found no organic cause despite extensive diagnostic investigations. A recent 2012 study in the Indian Journal of Pediatrics by Dr. B. Praveen and Dr. Johny Vincent reported the very rare case of a 10-year old girl who not only cried tears of blood but also sweated blood too (known medically as haematidrosis). She was successfully treated with propranolol (a beta-blocker often used to treat anxiety, panic and hypertension). More recently, Dr. K.M. Özcan and colleagues published the case of an 11-year old girl with haemolacria in the International Journal of Pediatric Otorhinolaryngology. The girl in question had been crying blood along with nosebleeds from both nostrils for two years before treatment was sought. Medical examination revealed that she had hyperaemia (i.e., the increase of blood flow to different tissues in the body, in this case the nose) and increased vascularity (i.e., bulging veins) in the nasal cavity.
The youngest case of haemolacria that I have come across in the medical literature was a 2010 paper by Dr. K. Kumar and colleagues in the journal Pediatric Allergy, Immunology, and Pulmonology. They reported an infant with immune thrombocytopenic purpura (a bleeding disorder where the blood doesn’t clot the way that it should) who arrived at a paediatric emergency department with bloody tears. The infant was treated with intravenous gamma globulin therapy (immunoglobulin injections that are given in an attempt to temporarily boost a patient’s immunity against disease).
It would appear that most cases of haemolacria have a distinct physiological cause but the cases where no organic cause was found suggest that psychological factors may play a role. This is certainly an area that I (no pun intended) will be keeping an eye on.
Dr Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK
Ahluwalia, B.K., Khurana, A.K. & Sood, S. (1987). Bloody tears (haemolacria). Indian Journal of Ophthalmology, 35(1), 41.
Freitas, T. G., Justa, V., & Soares, E. J. (1999). Bloody tears: Case report. Arquivos Brasileiros de Oftalmologia, 62, 628-630.
Kumar, K., Waseem, M., Panayiotopoulos, A., & Frieri, M. (2010). An infant with bloody tears in the Pediatric Emergency department: Evaluation and treatment – A case report and review of the literature. Pediatric Allergy, Immunology, and Pulmonology, 23, 207-210.
Mukkamala, K., Gentile, R. C., Rao, L., & Sidoti, P. A. (2010). Recurrent hemolacria: A sign of scleral buckle infection. Retina, 30, 1250-1253.
Özcan, K. M., Özdaş, T., Baran, H., Ozdogan, F., & Dere, H. (2012). Hemolacria: Case report. International Journal of Pediatric Otorhinolaryngology. 77, 137-138.
Ottovay, E., & Norn, M. (1991). Occult haemolacria in females. Acta Ophthalmologica, 69, 544-546.
Praveen, B. K., & Vincent, J. (2012). Hematidrosis and hemolacria: A case report. Indian Journal of Pediatrics, 79(1), 109-111.
Wiese, M.F. (2003). Bloody tears, and more! An unusual case of epistaxis. British Journal of Ophthalmology, 87, 1051.
Wieser, S. (2012). Bloody tears. Emergency Medicine Journal, 29, 286.
Wikipedia (2013). Haemolacria. Located at: http://en.wikipedia.org/wiki/Haemolacria