[Psychogenic purpura with hematuria and sexual pain disorder: a case report]

Psychogenic purpura (Gardner-Diamond syndrome) is the occurrence and spontaneous recurrence of painful ecchymosis following emotional stress and minor trauma. Although the exact mechanism of this syndrome remains unknown, apart from skin lesions, different types of hemorrhaging have been reported, such as epistaxis, gastrointestinal bleeding, and bleeding from the ear canals and eyes. We report a psychogenic purpura case that presented with hematuria in addition to skin lesions. Based on the psychiatric evaluation she was diagnosed with major depressive disorder, generalized anxiety disorder, and obsessive-compulsive disorder. Additionally, sexual pain disorder accompanied these disorders. With the help of antidepressant and supportive psychotherapy, the patient's ecchymosis and bleeding disappeared. During 8 months of follow-up the symptoms did not return. Vaginismus has not been reported in patients with psychogenic purpura. The presence of vaginismus, which is seen more frequently in eastern cultures and is thought to be related to sociocultural determinants, suggests that some cultural factors may be common to both psychogenic purpura and vaginismus. The aim of this case report was to call attention to a syndrome that is rarely seen and diagnosed, and to discuss its relationship to psychosocial factors. This syndrome should be considered in the differential diagnosis of not only ecchymotic lesions, but also various types of bleeding, including hematuria. Despite the fact that its etiology and treatment are not clearly understood, it should be noted that psychological factors play a role in this disease and therefore, psychopharmacological and psychotherapeutic approaches can be effective.

A case of psychogenic purpura in a female child

Recurrent spontaneous cutaneous bruising or bleeding through intact skin may be due to underlying emotional stress which may be due to auto-erythrocyte sensitisation. A 9-year-old female child presented with recurrent episodes of oozing from the skin of both lower eyelids and lower peri-orbital areas along with bleeding from tongue which ceased spontaneously after a few minutes without having any induration or oedema at the sites. The child had no systemic abormality, but she was nervous and attention seeking. Psychologic assessment revealed that she was suffering from conversion anxiety and somatoform disorder. After twelve psychotherapeutic sessions she showed marked improvement and her symptoms did not recur.

Periodic painful purpura: fact or factitious?

A 60-year-old woman with multiple psychosocial issues presented with a history of spontaneous painful bruising on her left upper arm. Extensive investigations did not reveal any abnormality apart from an elevated activated partial thromboplastin time as a result of factor XII deficiency. An autoerythrocyte sensitization test reproduced the tender bruises on her back. Our patient reported relief of pain with promethazine injections. She was subsequently referred to the psychiatric team for ongoing assessment and management. Having an awareness of this rare condition will assist in the prevention of unnecessary investigation of such cases and will allow the early referral of patients for appropriate psychological counselling.

Undiagnosed purpura: a case of autoerythrocyte sensitization syndrome associated with dermatitis artefacta and pseudo-ainhum

A 23-year-old young woman presented with recurrent episodes of painful bruising along with linear erosions on the accessible areas of the body of nine years duration with a pseudo-ainhum of her left nipple for the past three months. Her case history included repeated visits to various physicians at different centers and an extensive investigative profile. A diagnosis of autoerythrocyte sensitization was made on the basis of the clinical history, dermatological examination complemented by a positive autoerythrocyte sensitization test, psychiatric evaluation and absence of any organic cause for her ailment. She was placed on psychiatric management and has remained symptom-free after six months follow-up. The case is reported for its rarity, as well as for the association of autoerythrocyte sensitization syndrome with frank dermatitis artefacta and pseudo-ainhum, which to the best of our knowledge has not yet been reported in the literature.

Bathtub suction-induced purpura

We report two cases of bathtub suction-induced purpura. Two girls, ages 9 and 14 years, developed recurring purpura "spontaneously" in the same lower back location and in the same U-shaped distribution. The patients had similar histopathologic findings, with extravasated erythrocytes and a sparse superficial inflammatory infiltrate. After extensive evaluation, one patient eventually admitted to self-inducing her lesions by creating suction against a bathtub. The second patient denied self-inflicting her lesions; however, her purpura improved when she stopped taking baths.

Autoerythrocyte sensitization (Gardner-Diamond) syndrome mimicking compartment syndrome

We report a case with an unusual manifestation of autoerythrocyte sensitization syndrome (Gardner-Diamond syndrome). The patient had the clinical signs of compartment syndrome of the forearm requiring fasciotomy. Dermatological signs identical to Gardner-Diamond syndrome should alert the physician to avoid unnecessary fasciotomy, as these patients respond well to psychiatric treatment as in the present case.

Two cases of psychogenic purpura

Psychogenic purpura, also known as recurrent painful bruising or autoerythrocyte sensitization syndrome (Gardner-Diamond syndrome) is usually associated with emotionally disturbed patients. It is a troublesome entity for both patient and physician since extensive work-ups yield no diagnosis. We describe two females in their early twenties with recurrent painful bruising and diverse accompanying symptoms which appeared after physical trauma. One of the patients developed a bruise after intradermal injection of her own blood (with no reaction to saline injection). One patient had a personality (borderline) disorder, the other a factitious disorder. Punch biopsies revealed a perivascular inflammatory infiltrate, erythrocyte extravasation and no vasculitis. Psychogenic hemorrhagic disorders are uncommon yet must be considered in the differential diagnosis of purpura. Patients are usually young emotionally troubled females who present painful recurrent bruises on extremities frequently after trauma or surgery. Autoimmune mechanisms and increased cutaneous fibrinolytic activity have been implicated, although further studies are needed. Correct diagnosis is important to avoid aggressive and even mutilating treatments, and an adequate comprehension of these purpuras is important for the attending physician.

The mysterious case of the premenstrual purple chin

Recurrent episodes of a "purple chin" in an adolescent girl eluded definitive diagnosis for three years. The condition occurred premenstrually, but results of extensive tests failed to reveal any abnormal hormonal sensitivity. A diagnosis of factitial purpura was eventually established.

Stress, stigmatization and psychosomatic purpuras

Stress is a term that is readily recognized by everyone but defines rigorous scientific definition. It is widely interpreted as the emotional and biologic responses to novel or threatening situations. In humans, however, the term "distress" seems to be preferable, more clearly defining the fact that is the response that is being referred to, rather than the stimulus. Distress has been postulated to be capable of precipitating an overt illness, as when it occurs coincidentally with an incipient infection or neoplasm. Moreover, it is able to provoke several disorders and symptoms in many tissues and organs, including the skin. In this paper the authors focus on the main characteristics of stress and emphasize the relevance of psychosomatic medicine that proposes the simultaneous examination of psyche and soma. Special consideration is given to a peculiar form of skin disease, psychogenic purpura, together with the stigmata of mystics that, in large part, seem to be conditioned or provoked (or provocable) by emotional stress or by psychic influences on cutaneous fibrinolytic activity.

Autoerythrocyte sensitization syndrome (psychogenic purpura)

A case of autoerythrocyte sensitization syndrome is reported. This syndrome most often appears in young women who have an underlying emotional disorder; features include bizarre, tender ecchymotic lesions, which are most commonly located on the arms and legs. Systemic symptoms often accompany the onset of these lesions. A diagnosis of autoerythrocyte sensitization syndrome may be made in a patient who has the typical history and clinical picture of the syndrome and in whom a skin test with use of the patient's blood reveals a positive reaction.

[Gardner-Diamond syndrome]

This paper presents a 26-year-old woman with the characteristic features of Gardner-Diamond syndrome: recurrent painful bruises reproducible by intradermal injection of autologous red blood cells, and a "hysterical" personality pattern together with nonspecific multisystem complaints.

Psychogenic purpura: a most distressing case

A case of psychogenic purpura is likely to be unforgettable for everyone concerned. The patient's bizarre and dramatic appearance can frighten both the patient and medical personnel unfamiliar with the condition, causing panic and intense demands for drastic, inappropriate remedies. Our second experience with this condition was such a memorable case. We stress how difficult it can be to withstand the pressures of colleagues, the patient, and his or her family, and how important it sometimes is to be resolute regarding the need for conservative management.

Psychogenic purpura (autoerythrocyte sensitization): an unsolved dilemma

Experience at University Hospitals of Cleveland with 71 cases of Gardner and Diamond's syndrome of autoerythrocyte sensitization is reviewed. Gardner and Diamond attributed the pathogenesis of the inflammatory bruises typical of this syndrome to sensitization to the stroma of the patients' own erythrocytes, as demonstrated by reproduction of the lesion on intracutaneous injection of erythrocytic stroma. Nearly all the cases my colleagues and I have seen were in adult women, in whom the onset of inflammatory bruising could often be precisely dated, frequently some weeks after an injury or surgical procedure or, more often, severe emotional stress. Bouts of bruising were often preceded by sensations localized to the affected site. Cutaneous responses to the injection of erythrocytes were erratic. The patients described a wide range of both hemorrhagic and nonhemorrhagic complaints, including, among others, severe headaches, paresthesias, repeated syncope, diplopia (sometimes monocular), and "nervousness." Psychiatric studies indicated that patients had overt depression, sexual problems, feelings of hostility, and obsessive-compulsive behavior. The patients had traits that can be described as typical of a hysterical character disorder. Therapy of autoerythrocyte sensitization--that is, psychogenic purpura--has been difficult; in younger individuals, psychiatric therapy has appeared to be beneficial.

Diagnosis of autoerythrocyte sensitization syndrome in the emergency department

Autoerythrocyte sensitization syndrome is characterized by sudden and spontaneous painful bruising and swelling occurring in young female patients with psychiatric disorders. This syndrome may present with such severe swelling of involved areas that aspiration or excision may be needed to relieve pressure. The presentation of this condition in the emergency department must be differentiated from more common coagulopathies. Differentiation from the self-mutilation disorder, which often presents to the ED, can be difficult. Although the pathogenesis is uncertain, purpuric lesions are reproduced by injections of washed red cell erythrocyte stroma, suggesting an autoimmune etiology. We describe a patient with recurrent bruising diagnosed in the ED who responded with classic inflammation to autologous injection of red blood cells.

Analysis of the family structure in a case of psychogenic purpura

The case deals with an 18-year-old female patient suffering from psychogenic purpura who was successfully treated with individual and family oriented dynamic psychotherapy. Emphasis is placed on family dynamics and their possible bearing on the origin of the illness.

Psychogenic purpura in adolescent patients

The occurrence of psychogenic purpura has been documented in adults. The authors present their experience with nine adolescent and young adult patients observed since 1981. The age of eight of these patients ranged from 13 to 18 years. One patient with cystic fibrosis was 23-years-old. All patients presented with painful inflammatory lesions followed by bruising. There was no evidence of an infectious process or a hematologic, immunologic, or renal abnormality. Integral to the diagnosis was the existence of an underlying emotional disorder. In all patients, bruising decreased after diagnosis was explained to the patient and family. Four patients required psychotherapy. Results of 2-year follow-up suggest that early intervention may produce a favorable outcome in this age group.

[The Gardner-Diamond syndrome or painful recurrent ecchymotic purpura]

A case of Gardner-Diamond's syndrome is reported in which the lesions were localized to the face. The syndrome is characterized by the spontaneous onset of recurrent painful ecchymoses mainly in young women. The elective site of the lesions is on the limbs, sometimes on the abdomen or thorax, and only rarely on the face. They are accompanied by a very rich symptomatology contrasting with normal biological test results. An autoerythrocytic sensitization mechanism has been suggested but few biological arguments exist to support this auto-immune hypothesis of its origin. In contrast, the psychological background is hysterical in type, and the affection can be included among the psychogenic purpuras.

Autoerythrocyte sensitization

We have seen six examples of autoerythrocyte sensitization in children that allow a definition of the disorder in the pediatric age group. The typical skin lesion is a painful, erythematous bruise that starts after minor trauma or surgery and often involves an area away from the injury site. The skin manifestations can be debilitating, and reappear unpredictably for an indefinite period. Somatic symptoms can be associated with the bruising. Usually the children have a disturbed psychological background. Characteristically, multiple detailed investigations are performed before the diagnosis is made. An intradermal injection of autologous red cells may or may not give a "positive" ecchymotic reaction. Pediatric patients seem to respond well to psychotherapy, which is usually the only effective form of treatment.

[Psychogenic purpura]

A 27 year old women revealed chronic relapsing, spontaneously developing hematomas without coagulopathy. The lesions were reproducible by intradermal injection of erythrocyte membranes as well as DNA. Positive test reactions could be elicited or suppressed by psychological influences on the patient. This case and similar reports in the literature raise the question whether Gardner-Diamond syndrome and the autosensitization to DNA are different entities.

[Psyche and skin (author's transl)]

The important psychological functions of the human skin - the skin functions as a border, contact and sense organ and as an organ of expression - as well as causalgenetic aspects of psychodermatology and the most important psychodermatological diseases are reported. Frequent psychosomatic dermatoses like chronic urticaria (bibliography), pruritus (case report, perioral dermatitis and alopecia areata (case reports) are described. In atopic dermatitis, psoriasis vulgaris and acne rosacea psychological factors are involved in addition to constitutional factors. Psychovegetative dermatoses can be due to situational problems (stress), but dermatologic symptoms may also have a mere appellant character (e.g. slight effluvium). Dermatologic symptoms may occur in connection with psychoses (e.g. parasitophobia). Psychic dermatologic symptoms may also arise secundary to severe chronic dermatoses. In psychoneurotic diseases such as dermatitis arterficialis skin is the target organ. Therapeutical aspects are considered.

Psychogenic purpura: report of a case

Autoerythrocyte sensitization, a disease characterized by recurrent and painful ecchymoses, was renamed psychogenic purpura by Agle and Ratnoff in 1968. The patients, usually female, share certain described personality characteristics. The case is reported of a 20-year-old woman who had suffered from the disease since age 12. She was treated for 3 years in intensive psychotherapy resulting in a complete remission of her symptoms of bleeding.