When emotions bleed: A case report on hematidrosis with borderline personality disorder

Dear Editor, Borderline personality disorder (BPD) is a condition marked by unstable relationships, self-image disturbances, affective instability, and impulsivity.1 Hematidrosis, a rare disorder, involves excretion of blood or blood-stained fluid through intact skin, often triggered by emotional, or physical stress.2 The likely mechanism is stress-induced constriction and sudden dilation of small vessels around sweat glands, causing them to rupture. Blood enters the sweat glands and is expelled with sweat, appearing as blood-stained droplets. The leaked blood contains the same cellular components as peripheral blood.3 We report a case highlighting the psychosomatic interplay between BPD and hematidrosis. A 15-year-old girl presented with bleeding episodes from intact skin, suspected to be self-inflicted, owing to symptoms of BPD. During admission, her vitals including BP were normal and the treating team directly observed oozing of blood (Benzidine test positive) from her forehead and forearms, during episodes of emotional distress. The bleeding was painless, lasted minutes, stopped spontaneously, and left no scars. Investigations including coagulation profile (Prothrombin time (PT), Activated partial thromoplastin time (APTT), INR, Factor VIII/IX levels, Direct Coomb’s test), Antinuclear antibody (ANA) profile, MRI brain, and skin biopsy—were all normal, excluding hematological, or dermatological pathology. The biopsy showed red blood cells with lymphocytes but no specific abnormality.Psychosocial assessment revealed marked sensitivity to rejection and feelings of neglect, particularly in relation to parental attention toward her younger sibling. Emotional stress consistently precipitated bleeding episodes. She fulfilled DSM-5 criteria for BPD and was diagnosed with hematidrosis. She was treated with low-dose risperidone and oxcarbazepine to reduce emotional reactivity, along with dialectical behavioral therapy and regular counselling. Over follow-up, emotional outbursts and bleeding episodes decreased but persisted during severe stress. Addition of propranolol 20 mg reduced the frequency of bleeding, though episodes continued during marked emotional turmoil. Hematidrosis remains a diagnostic challenge given its rarity and absence of specific laboratory findings. Diagnosis is largely clinical and by exclusion.2,4 In this case, co-occurring BPD was highly relevant, as its hallmark features—affective instability, impulsivity, and stress sensitivity—likely contributed to the autonomic dysregulation triggering bleeding.1 The case underscores the complex mind-body interface, where extreme psychological distress can manifest as rare somatic phenomena. Treatment required both pharmacological stabilization and psychotherapeutic interventions, with partial improvement. This report highlights a rare association between BPD and hematidrosis, emphasizing the need for comprehensive biopsychosocial evaluation, and multidisciplinary management. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.