Recurrent bilateral periorbital and circumoral bruising due to vomiting

Periorbital ecchymosis is due to extravasations of blood into the periorbital skin and the subcutaneous tissues around the eyes. 'raccoon eyes' or 'panda sign' is a distinctive type of periorbital ecchymosis where the bruising is characterised by tarsal sparing. This sparing is due to an anatomical structure called the orbital septum, which limits the spread of the discolouration beyond the tarsal plate. Hence 'raccoon eyes' description should be limited to orbital ecchymosis due to basal skull fractures only. While the bilateral bruising due to direct trauma to the eyes, or non-traumatic medical conditions, can spread beyond the tarsal plate as in our case. The differential diagnosis varies from trivial benign conditions to serious life-threatening illnesses. We describe a case of recurrent bilateral periorbital ecchymosis and facial bruising due to vomiting.