Epistaxis, the medical term for a nosebleed, is a relatively common occurrence that can be caused by various factors, including simple nasal irritation or trauma. Respiratory viral infections frequently lead to symptoms like nasal congestion and inflammation, which can irritate the delicate lining of the nose. Clinical observations during the pandemic have indicated a specific relationship between SARS-CoV-2 infection and an increased incidence of nosebleeds in some patients. This connection involves both the direct action of the virus on the nasal passages and the systemic effects the illness has on the body’s vascular and clotting systems.
The Direct Link Between COVID and Epistaxis
The SARS-CoV-2 virus initiates infection by binding to the angiotensin-converting enzyme 2 (ACE2) receptor on human cells. The nasal cavity is a primary site for viral entry and replication because the epithelial cells lining the upper respiratory tract have a high concentration of these ACE2 receptors. This direct viral action induces significant inflammation (rhinitis) within the nasal passages.
The inflammatory response causes irritation and swelling of the nasal mucosa, which is rich with tiny, fragile blood vessels. When this lining is inflamed, the blood vessels become more susceptible to damage and rupture, leading to a nosebleed. Studies suggest a direct association, indicating that for some individuals, a nosebleed may occur as a consequence of the viral infection itself.
Indirect Causes Related to Viral Symptoms
A severe respiratory illness often brings mechanical factors that increase the risk of a nosebleed. Excessive or forceful nose blowing, due to nasal congestion or a runny nose, can easily damage the already inflamed nasal lining. This physical trauma puts strain on the fragile blood vessels near the surface, causing them to break and bleed.
Another common factor is the physiological dryness associated with illness. Fever and general dehydration can dry out the nasal mucosa, making it cracked and brittle. Furthermore, many hospitalized patients required supplemental oxygen delivered via a nasal cannula, which significantly dries out the nose. Dryness leads to crust formation, and when these crusts are dislodged, they can pull away the underlying tissue and cause bleeding.
Systemic Factors and Treatment Side Effects
The most complex causes of nosebleeds relate to the systemic effects of the disease. COVID-19 triggers a state of dysregulated blood clotting, medically termed coagulopathy. This condition involves widespread inflammation that can lead to both excessive clotting and, paradoxically, an increased risk of bleeding. The virus’s impact on the lining of blood vessels contributes to this systemic dysregulation.
To prevent life-threatening complications like deep vein thrombosis or pulmonary embolism, high-risk patients are often treated with anticoagulant medications (blood thinners). The use of therapeutic-dose anticoagulants is a major side effect risk for bleeding. While these treatments counteract severe clotting, they inherently increase the likelihood of bleeding from sites with fragile vessels, such as the nose. Studies confirm that a high percentage of patients experiencing epistaxis were actively receiving anticoagulant therapy.
Recognizing When to Seek Medical Attention
While most nosebleeds resulting from a viral illness are minor and resolve on their own, certain signs indicate the need for professional medical evaluation. Bleeding that is heavy, prolonged, or difficult to stop requires attention. Specifically, if a nosebleed continues steadily for more than 20 minutes despite applying direct pressure, seek immediate care.
Recurrent nosebleeds, or any nosebleed accompanied by other signs of significant blood loss like dizziness or weakness, also warrant a medical consultation. If you are currently taking any blood-thinning medication, a healthcare provider should be notified about any new or frequent bleeding episodes. In complex cases, patients may require evaluation by a specialist for procedures like cautery or nasal packing to manage the bleeding.