Painful bruising syndrome presenting as bullous lesions.

Sir,

A 34-year-old female presented with dark-colored lesions on left cheek, arms, and thighs preceded by burning sensation. These lesions evolved with swelling, tenderness, and blister formation. She had one episode of hematemesis three months back for which she had received blood transfusion. The patient reported increased worrying associated with familial, financial, social and interpersonal stressors, along with increased irritability, anger outbursts, and low mood. A diagnosis of painful bruising syndrome was made based on dermatological findings and psychiatric evaluation. Psychiatric management of the patient relieved her of dermatological signs and symptoms. Few cases have been reported with painful bruises along with psychological problems.

Painful bruising syndrome is a rare condition with ecchymotic skin lesions preceded by burning or stinging followed by warmth, erythema, swelling, and sometimes pruritis, accompanied by bleeding from other sites presenting with hematemesis and occasionally hematuria.[12] It commonly affects adult women with underlying psychiatric problems, with female to male ratio 20:1.[3] The lesions are often preceded by a significant psychosocial stressor.[34] The patient may present with comorbid psychiatric disorders like conversion disorder, depression, anxiety and personality disorders. Frank Gardner and Louis Diamond first described four adult women with painful ecchymoses in 1955, reproducible after injection of their own RBCs.[3] Some cases have been reported with negative autoerythrocyte sensitization test.[5]

A 34-year-old female presented with dark-colored lesion on left cheek, preceded by burning sensation for two days. After 15 days, she developed burning sensation over right arm [Figure 1] and left leg [Figure 2] followed by swelling and tenderness with discoloration and blister formation. She also developed similar lesion over left thigh and burning sensation over left ankle. She had no history of similar lesions in the past.

Figure 1

Fluid filled lesions on right arm with oozing and crusting

Figure 2

Purpuric lesion with erythema,oedema and blistering on left leg

She had one episode of hematemesis three months back for which she had received blood transfusion.

On dermatological examination, the lesions were hyperpigmented, purpuric, edematous, fluid filled and tender. The hair, nails, and mucosae were spared.

Routine hematological investigations were done, which revealed Hb 8gm%.

Intracutaneous sensitivity test was not contributory.

Psychiatric referral was done. The patient reported increased worrying associated with familial, financial, social, and interpersonal stressors, which were ongoing for last 3–4 years. She also complained of increased irritability and anger outbursts, low mood, since 3–4 months, and had sleep disturbances. She had prominent suicidal ideation and had attempted suicide twice in the last month.

Histopathological findings of the lesion revealed subcorneal vesicle showing edema, dense acute on chronic inflammatory infiltrate composed of neutrophils, eosinophils, plasma cells, and lymphocytes. The bullae also showed moderate amount of brown pigment. Superficial and deeper dermis also showed extravasation of RBCs and hemorrhage at places.

The patient was treated with systemic antibiotics, vitamin C, Tablet Doxepin 25 mg, Tablet Escitalopram 10 mg, Tablet Trifluperazine 1 mg, Tablet Clonazepam 0.5 mg. Following that the lesions resolved and no new lesions evolved at the site of burning. She was discharged from the hospital with advice to continue these drugs. At home, she failed to continue the treatment. Her husband who was alcohol dependent continued to abuse her and familial interpersonal conflicts persisted. New lesions developed over her hands, thighs, and face. They followed the same course as the earlier lesions. The patient was rehospitalised and the treatment was restarted.

Painful bruising syndrome has been reported with ecchymotic lesions preceded by stinging sensation accompanied by hematemesis and occasionally hematuria.[2] Some of them may present with cellulitis.[6] Cases of dermatitis artefacta associated with ecchymotic lesions have been reported.[7] Patients presenting with this disorder mostly have underlying psychiatric manifestations. A significant psychosocial stressor may be a precipitating factor.[48] Cyproheptadine has been used in the management of such cases with variable results.[19] Although most of the patients reported positive autoerythrocyte sensitization, this was not so in our case.

Presence of fluid filled lesions is an unusual finding. Treatment of the patient with anti-depressives resulted in remission if skin lesions. Management of patient in consultation with a psychiatrist was utmost important in this case.

The authors would like to acknowledge Dr. Sanjeevani Thombre, Dr. Seemantini Unawane, and Dr. Sneha Joshi.