Spontaneous haemorrhage in an eyelid hidrocystoma in a patient treated with clopidogrel

Sir,

Hidrocystomas are benign cystic tumours of the sweat glands that frequently occur in the periocular region. Rarely, more serious pathology such as basal cell carcinoma or malignant melanoma may resemble and be mistaken for hidrocystoma.^{1, 2} We report a very unusual presentation of spontaneous bleeding within a hidrocystoma, mimicking a malignant melanoma.

Case report

A 62-year-old woman presented with a lesion on the medial aspect of the left upper lid, which was slowly enlarging over 2 years and darkened 6 months earlier. She admitted to having excessive sun exposure in the past, and her past medical history included hypertension, type II diabetes, and peripheral vascular disease. Her regular medications were insulin, metformin, simvastatin, ramipril, and clopidogrel.

Examination revealed a curious lesion on the medial aspect of the left upper lid (Figure 1a). The lesion, which appeared cystic and lobulated, was mostly skin coloured with surface telangiectasia and purple–blue discoloration inferiorly. Although a benign lesion was suspected, the unusual appearance prompted excisional biopsy. Histopathological examination showed a papillary hidrocystoma with apocrine differentiation, featuring small lakes of blood within the myxoid material occupying the lumen (Figure 1b).

Figure 1

(a) Clinical appearance of the cystic lesion on the medial aspect of the left upper lid with telangiectatic vessels on the surface and localised purple–blue discolouration inferiorly. (b) Subcutaneous cyst lined predominantly by papillary apocrine and conventional double-layered hidrocystoma epithelium, and containing small lakes of blood (arrow) within the luminal basophilic myxoid material (H&E × 10).

Comment

Apocrine hidrocystomas usually present as slow-growing, solitary, or multiple small, tense, dome-shaped, thin-walled cysts. They are usually translucent, skin-coloured lesions, but are occasionally lightly or deeply pigmented. Histologically, they are characterised by a unilocular or multilocular cystic space in the dermis with a lining consisting of a double layer of epithelial cells.¹ Although there is a single case report of a giant apocrine hidrocystoma presenting as a tense haematoma of the scalp,³ to the best of our knowledge there are no published reports of eyelid hidrocystomas presenting with spontaneous bleeding within the lesion. A possible predisposing factor for intralesional bleeding in our case was regular use of clopidogrel, an antiplatelet agent that has been associated with spontaneous haematomas at other sites.^{4, 5}