Haemolacria bloody tears A perplexing symptom A report of two cases.html

Niger J Paed 2015; 42 (1): 68 –70

CASE REPORT

Oyenusi EE

Haemolacria (bloody tears): A

Ananti CH

perplexing symptom: A report of

two cases

DOI:http://dx.doi.org/10.4314/njp.v42i1,15

Accepted: 6th August 2014

Abstract: We present two cases

not recurred after being followed

of a boy and a girl (both aged four

up for two years.

Oyenusi EE

(

)

years) who presented with bloody

The second patient, presented with

Department of Paediatrics,

tears. (haemolacria). The boy ini-

redness of the eyes and yellowish

Lagos University Teaching Hospital,

Idi-Araba, Lagos

tially presented with cough,

mucoid discharge of six days, low-

Email: ebikike@yahoo.com

catarrh and three episodes of epis-

grade fever of three days and spon-

taxis. Full blood count, coagula-

taneous bloody tears from both

Ananti CH

tion profile, bleeding time, blood

eyes. There was associated orbital

Motayo Hospital Limited,

film picture and X-ray of the post-

cellulitis and vomiting of non-

3 Owodunni Street, Ikeja, Lagos

nasal space were normal. He

bloody recently ingested feeds.

started shedding blood stained

Blood investigations were sugges-

tears initially on crying, two

tive of sepsis and assays of meas-

weeks later without associated

ured clotting factors and coagula-

epistaxis.

Subsequently

the

tion profile were normal. She was

bloody tearing became spontane-

managed with antibiotics and im-

ous. He was given intramuscular

proved with resolution of haemo-

vitamin K and high dose vitamin

lacria which has not recurred dur-

C. Other relevant investigations to

ing a follow up period of six

determine the cause could not be

months.

done due to financial constraints,

however

the

bloody

tearing

Key words: Bloody tears, haemo-

stopped after two months and has

lacria, children.

Introduction

Case presentation

Case 1

Haemolacria (bloody tears) is a rare occurrence. This

rarity is alluded to in a local Nigerian (Ibo) proverb

TA, a four-year old boy initially presented in a private

which when translated means “there is nothing that the

hospital with cough, catarrh and three episodes of epis-

eye sees and cries blood, it can only cry water”. How-

taxis. There was no history of trauma, no previous

ever when haemolacria occurs, it may be a cause of

bleeding episodes nor a family history of bleeding disor-

panic for the patient or care givers and may perplex the

ders. He was placed on Otrivin ® nasal drops, Actifed ®,

doctor. It was first described by Dodanaeus

Cefuroxime, and a stat dose of diacynone. Full blood

1581where he recorded his observations on a girl who,

count, coagulation profile, bleeding time, blood film

at the age of 16, had not menstruated. Haemolacria can

picture and X-ray of the postnasal space were normal.

be caused by diseases of the conjunctiva, eyelids and

He started shedding blood–stained tears initially on cry-

nasolacrimal system or trauma . Epistaxis with retro-

ing, two weeks later without associated epistaxis. Subse-

grade flow, vascular malformations, inherited bleeding

quently the bloody tearing became spontaneous. The

disorders, acquired systemic coagulopathies, vicarious

eyes were grossly normal. Assays for Factors VIII, IX

menstruation, drugs, hyperthyroidism, nasolacrimal tu-

and Von Willebrand factor, a nasolacrimal irrigation and

berculosis, hysteria/stigmatization and malingering have

biopsy, CT Scan and/or MRI of the head and orbit were

also been implicated . Haemolacria can also be idio-

3-9

planned for but the health insurance did not cover the

pathic .

expenses and the parents had financial constraints. He

We report these two cases to draw attention of clinicians

was given empirical therapy of IM Vitamin K for three

days and placed on high dose Vitamin C (500mg daily) .

to this unusual condition and highlight management

challenges.

Two months later, the bloody tearing stopped spontane-

ously and he has been stable for about 18 months.

Case 2

girl with an upper respiratory infection and blood-

stained tears upon crying vigorously which subsided

SA, a four year old female, presented in the above pri-

simultaneously with the clearing of the infection. A

vate hospital (about a year after Case 1) with redness of

similar scenario was seen in our second patient whose

the eyes and yellowish mucoid discharge of six days,

bloody tearing resolved with recovery from the infective

low-grade fever of three days and spontaneous bloody

episode.

tears from both eyes. There was associated gradual pain-

Ho et al also documented spontaneous bloody tearing in

ful swelling of the eyes which occluded the right eye

and also impaired her vision. There was associated pro-

a case series comprising a six-year old boy and three

jectile vomiting, which was neither blood-stained nor

girls ( two aged 12 years and one 14 years) over an 11-

bilious but contained recently ingested feeds. There was

year period. These patients had extensive work which

no bleeding from any other body orifice. However there

failed to suggest a cause. The bloody tearing eventually

was a history of frequent uncontrollable flow of tears

resolved in all these patients without further sequel nor

without any emotional involvement since birth. On ex-

recurrence over a follow-up period of 9 months to 11

years .

amination,

she

was

acutely

ill

looking,

febrile

(temperature of 38.2°C) and had bilateral hyperaemic

swollen eyes with yellowish discharge and intermittent

Evaluation and management of haemolacria is multidis-

shedding of bloody tears. Full blood count was sugges-

ciplinary. A thorough history, a careful eye examination

and an otolaryngologic examination are essential . Ex-

tive of sepsis. Coagulation profile and eye swab micros-

copy were normal while culture yielded no growth. She

tensive workup is also required to establish a diagnosis.

was commenced on intravenous antibiotics (Augmentin

When one is suspicious about the nature of the red mate-

and Gentamicin) and chloramphenicol eye drops. Fac-

rial such as suspected hysteria and malingering, micros-

tors VIII and IX assays were normal. CT scan of both

copy and tests to detect and analyze blood are worth-

while .

eyes and lacrimal gland biopsy were planned after re-

view by the ophthalmologist though not eventually done

due to financial constraints. The child improved with

Treatment is guided by the aetiology. These may include

resolution of symptoms. She is being followed up and

administration of antibiotics, correction of a bleeding

has not had any bloody tears for six months.

diathesis, tumor removal, hormonal therapy, antituber-

culous drugs, anti-thyroid medications or psychother-

apy

3-5,7-9

. High dose vitamin C has been postulated to be

effective in bloody tearing caused by chronic inflamma-

tory conditions . In our first patient, it is not easy to at-

tribute resolution of haemolacria entirely to Vitamin C

therapy. Close observation with reassurance is needed in

idiopathic cases as most will resolve spontaneously.

Counseling and psychological support for patients and

family is useful in helping the family to cope with possi-

ble discrimination and stigmatization especially in

superstitious settings.

Discussion

Conclusion

Different isolated cases of haemolacria are reported in

In conclusion, haemolacria is an uncommon but worri-

literature. All age groups can be affected from infancy to

some clinical phenomenon. Management involves a

the elderly which would as expected be related to the

multidisciplinary approach. Financial constraints may

causative factors. There is no obvious sex preponder-

constitute a challenge in full evaluation and management

ance except where the primary disease has a gender bias

in resource-constrained settings. Follow up of patients is

such as hyperthyroidism or hysteria . Coincidentally,

recommended.

our patients were both four years old at presentation but

a male and a female respectively.

Authors Contributors

Some reports have documented haemolacria accompa-

OEE : managed the first case

nying epistaxis as was seen initially in our first patient.

3,4

ACH : managed the second case. Both authors wrote

The anatomical basis of this occurrence lies in the inti-

and reviewed the manuscript.

mate connection of nose and eye via the lacrimal appara-

Conflict of interest: None

tus . An increase in pressure within the nasal cavity dur-

Funding: None

ing epistaxis can cause retrograde flow of blood through

the system and thus lead to bloody tears emerging from

the ipsilateral eye . Other reports of bloody tears in early

childhood include Scott, who described a 6-month-old

Acknowledgements

We also appreciate the Management of Motayo Hospital

Limited for permission to use their patients’

The authors wish to thank the parents of the patients for

information.

their consent to use the information and photographs.

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