An elderly patient crying out blood: a case report

¹Otorhinolaryngology Department, Military Training Hospital Mohamed V of Rabat, Rabat, Morocco

^&Corresponding author
Marouane Balouki, Otorhinolaryngology Department of the Military Training Hospital Mohamed V of Rabat, Rabat, Morocco

Introduction    

Haemolacria is a rare hemorrhagic manifestation during which tears consist partially or exclusively of blood. This manifestation is most often unilateral. The etiologies of this manifestation are varied. The most common are inflammation, lacerations or infection of the conjunctiva, eyelid and tear ducts [1]. There are other rarer causes such as lacrimal tumors, retrograde epistaxis, vascular malformations and constitutional or acquired hemorrhagic syndromes. Most cases of haemolacria are mild and progress without complications after identification and management of the triggering factor [2]. We report the case of a 72-year-old patient referred to ENT consultation for haemolacria associated with epistaxis.

Patient and observation     

Patient information: a 72-year-old patient admitted to our department with the right unilateral haemolacria which presents for the first time, accompanied by abundant one-sided epistaxis on the right side (Figure 1). The patient's medical history reveals no hemorrhagic disorders which can cause bleeding, he was not taking any anticoagulant treatment. However, the patient had been followed in cardiology for arterial hypertension for 10 years.

Clinical findings: the endoscopic examination of the nasal cavities revealed an inflamed right nasal mucosa which bleeds abundantly in sheets, the left mucosa was normal. The ophthalmological examination came back without particularities. Bilateral anterior segments, fundus and vision were normal.

Diagnostic assessment: laboratory tests revealed a normal complete blood count (hemoglobin and platelet count) and coagulation profile (platelets, active bleeding time, prothrombin level and fibrinogen). Sinus and facial computed tomography revealed no pathology other than inflammatory mucosa (Figure 2).

Diagnosis: at the end of the clinical, endoscopic, biological and radiological explorations, retrograde epistaxis was retained as the etiology of hemolacria given the abundance of epistaxis and the negativity of the assessments.

Therapeutic interventions: the patient was wicked by a merocel in the right nasal cavity, his eye was washed with physiological saline after the nasal bleeding had stopped. Then he was put on Amoxicillin for 7 days.

Follow-up and outcome of interventions: after nasal packing; the epistaxis stopped and therefore the haemolacria stopped. The patient was seen again after 72 hours to remove the merocel. He evolved well after this therapeutic intervention because he did not bleed again afterwards.

Informed consent: informed consent was obtained from the patient.

Discussion     

Haemolacria is a relatively rare syndrome, manifesting as tears made up of blood. In most cases, a traumatic, inflammatory, infectious, vascular, oncological, iatrogenic cause or a coagulopathy is found. It can also be the mechanical consequence of retrograde epistaxis. Following an epistaxis, the increase in nasal pressure can cause haemolacria. Also, the otolaryngological surgery may be the cause of this manifestation [3]. During nasal epistaxis, blood passes through the Hasner-Bianchi valve, enters the lacrimonal duct and, following an antidromic direction toward the normal tear, emerges into the lacrimal basin through the punctum. The most frequent origins of blood leaving the lacrimal point are epistaxis produced by general vascular and blood diseases or rhinitis. It can also be produced by tumors, foreign bodies or contusive trauma. Rarely, it can come from the trachea or the upper digestive tract. When the blood comes from a nasal hemorrhage, it rarely rises spontaneously through the lacrimal passages and comes out through the lacrimal point; this abnormal directional flow can occur when epistaxis is treated with a nasal swab, allowing blood from the nasal cavities to back up through the lacrimal ducts ways [4]. Usually the pinpoint flow of blood is slow, but arnal cited a patient with epistaxis who, for several minutes after nasal packing, had a stream of blood through the colon of the right eye punctum [5]. It´s exceptional when blood appears through the punctum without a nasal tamponade the case reported. Sometimes the bleeding through the punctum lasts longer than the epistaxis, which may suggest that the bleeding originated in the lacrimal duct. When blood comes from lacrimal duct or epistaxis and empties into the lacrimal pelvis, it exits most often through the inferior punctum, sometimes through both inferior and superior puncta, and rarely through the superior punctum only [4].

Conclusion     

Haemolacria generates certain anxiety due to its “impressive” character for the patient. In view of the situation described above, a complete assessment must be carried out to allow optimal management. The ophthalmological examination is essential in first intention and allows in the majority of cases to determine the etiology of this hemorrhagic manifestation. The etiology of retrograde epistaxis by lacrimal passages should not be forgotten, the diagnosis is clinical but before retaining it, it is necessary to do a biological and radiological assessment to eliminate another local or general cause.

Competing interests     

The authors declare no competing interests.

Authors' contributions     

MB and KO wrote the article. NE and BH have reviewed the literature. AJ and FB are responsible for the corrections. All authors have read and approved the final manuscript.

Figures     

Figure 1: a photo of the patient showing bloody tears in the right eye associated with active epistaxis

Figure 2: computed tomography scans of the nasal cavities normal findings (A: coronal slice; B: axial slice)

References