Bloody Tears, Gardner-Diamond Syndrome, and Trigemino-Autonomic Headache

Abstract

CASE A 38-year-old woman presented with shortlasting right-sided, knife-like headache associated with miosis, conjuctival injection, and lacrimation. Four days later, bloody tears in the right eye and bleeding in her right nostril appeared during the headache attacks, lasting approximately 15 minutes. She tried acetaminophen for pain control without relief and denied use of anti-inflammatory drugs or other medications. Her physical examination, including an ophthalmologic evaluation, was unremarkable except for the presence of bloody tears in her right eye during headache attacks (Figure A) and painful ecchymoses of the upper limbs (Figure B). Prothrombin time, activated partial thromboplastin time, complete blood count, microscopy of a peripheral blood smear, evaluation for von Willebrand disease, and platelet function testing were normal as were skin biopsies. Antinuclear and antiphospholipid antibodies were negative. A brain magnetic resonance imaging with magnetic resonance angiography was unremarkable. Malingering and factitious disorder were ruled out because the physicians witnessed the bloody tears several times. A psychiatric evaluation suggested an adjustment disorder in response to the disease. She received the diagnosis of Gardner– Diamond syndrome (psychogenic purpura or painful bruising syndrome). The headache attacks improved with oxygen inhalation. Verapamil rendered her pain free. One year later, the attacks recurred with bloody tears.