Comment on ‘Spontaneous haemorrhage in an eyelid hidrocystoma in a patient treated with clopidogrel’

Sir,

We read with interest the article on ‘Spontaneous haemorrhage in an eyelid hidrocystoma in a patient treated with clopidogrel’ by Novitskaya et al.¹ We agree with the authors that eyelid apocrine hidrocystomas typically present as skin-colored, translucent lesions. However, our experience has shown that hemorrhagic hidrocystomas may be more common than previously reported, with or without a history of clopidogrel use. Here, we describe two cases of hemorrhagic apocrine hidrocystomas. Both of the hidrocystomas underwent excision and pathologic examination.

A 78-year-old male with a history of coronary artery disease on systemic clopidogrel and aspirin presented for evaluation for a non-painful, pigmented eyelid lesion. The patient was uncertain of the exact time of onset of the lesion, but felt that it was stable for the past 2 months. He denied any preceding trauma to the periocular tissue. Examination revealed a translucent dome-shaped cystic lesion along the left upper eyelid (Figure 1a). Detailed examination revealed a horizontal, linear demarcation suggestive of layered hemorrhage. Histological evaluation of the lesion revealed a cystic structure, consistent with apocrine hidrocystoma (Figure 1b). The lumen of the cyst contained degenerated erythrocytes and abundant hemosiderin-laden histiocytes, consistent with old hemorrhage.

Figure 1

(a) Clinical appearance of the cystic lesion along the medial aspect of the left upper eyelid with a flesh-colored base and a deep purple hue at the apex. A horizontal, linear demarcation within the cyst was observed, representing layered hemorrhage. (b) Histologic analysis of the cyst in panel a demonstrated an inner layer of eosinophilic cuboidal to columnar epithelium showing focal decapitation type secretion, consistent with apocrine hidrocystoma, while the lumen contained abundant hemosiderin-laden histiocytes and degenerated erythrocytes. (c) Clinical appearance of the cystic lesion along the medial aspect of the right upper eyelid. (d) Histologic analysis of the cyst in panel c demonstrated eosinophilic columnar cells lining of the cystic lesion. The inner layer of columnar cells showed decapitation secretion, focal lipofuscin pigment deposition and focal ciliary processes, all consistent with apocrine hidrocystoma, while the cyst lumen contained degenerated and intact erythrocytes.

A 59-year-old male with a history of dyspnea and allergic rhinitis on systemic aspirin presented for evaluation of a violaceous lesion on the upper eyelid. This lesion had been present for 4 years with recent growth in size. He denied any preceding trauma to the periocular tissue. Examination revealed a cystic, well-circumscribed, violaceous lesion superior to the right upper lid margin (Figure 1c). Histological evaluation of the lesion demonstrated a cystic lesion consistent with apocrine hidrocystoma (Figure 1d). The lumen of the cyst contained intact and degenerated red blood cells consistent with recent and old hemorrhage, respectively.

We suggest that hemorrhagic apocrine hidrocystomas of the eyelid are more common than previously reported, and may be seen in the setting of minimal systemic anticoagulation, including aspirin use alone.