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Leech Endoparasitism: Report of a Case and Review of the Literature

Leech Endoparasitism: Report of a Case and Review of the Literature
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  ORIGINAL PAPER  Leech endoparasitism: report of a case and reviewof the literature Farhad Montazeri  &  Arash Bedayat  &  Layli Jamali  & Mehran Salehian  &  Ghoderat Montazeri Received: 5 December 2007 /Accepted: 26 February 2008 / Published online: 12 June 2008 # Springer-Verlag 2008 Abstract  We report the case of an 11-year-old boy who presented with fresh blood in his mouth and a history of sore throat during the past 2 weeks that was unresponsive toantibiotic therapy. Inspection of the oral cavity revealed a black circular mass attached to the posterior wall of theoropharynx. This mass was determined to be a live en-gorged leech. Leech endoparasitism is caused by aquaticleeches that attach themselves to mucus membranes of  body cavities after the host has swum in bodies of freshwater or drunk from unsafe water sources. Pharyngealhirudiniasis may present in different forms depending onthe exact location of the parasite in the body and must beincluded in the list of differential diagnosis for commonconditions such as pharyngitis, hemoptysis or anemia in pediatric patients living in endemic areas. Keywords  Airwayobstruction.Anemia.Hematemesis.Leeches.Pharyngitis Introduction Leeches are segmented worms that have been known tohumans for thousands of years [19]. Saliva of hemophagicleeches contain anesthetic, vasodilator, protease inhibitor and anticoagulant substances (hirudine, saratin), all of which makes these creatures excellent blood-suckingmachines [18  –  20]. This capability has drawn attention of clinicians throughout history. Although not as frequently asthe past, leeches are still of therapeutic importance inmodern plastic surgery (especially in the case of reducingvenous congestion of tissue flaps) [4, 18]. In addition to the classic picture of leeches as an external parasite, these organisms can also reach internal body organsand cavities, including the nasopharynx, larynx, vagina and bladder. By attaching to mucous membranes and feedinginside these spaces, leeches cause the clinical syndromeknown as  ‘ internal hirudiniasis ’ .We report here the case of an 11-year-old boy who presented with pharyngeal leech infestation. We discussinternal hirudiniasis and related differential diagnoses andreview medical literature related to this condition. Eur J Pediatr (2009) 168:39  –  42DOI 10.1007/s00431-008-0706-1F. Montazeri ( * ) : G. MontazeriDigestive Disease Research Center, Shariati Hospital,Medical sciences/Tehran University,72, Karegar Shomali Avenue, 17th street,1438837431 Tehran, Irane-mail: farhadmontazeri@gmail.comG. Montazerie-mail: A. Bedayat Iran University of medical sciences,#19. Farzan st, Naji st, Zafar ave,Tehran, Irane-mail: arashbedayat@yahoo.comL. JamaliIran University of medical sciences,#20, Sepand st, Aqdasieh ave,Tehran, Irane-mail: layli_j@yahoo.comM. SalehianIran University of medical sciences,#28, Heidarian st, Falamak ave,  “ Shahrak e gharb ” ,Tehran, Irane-mail:  Case presentation An 11-year-old boy was referred to our rural healthcarecenter in central Iran complaining of fresh blood in hismouth. This was his first such episode, and it had lasted for 30 min. He had a history of sore throat during the past 2 weeks that was unresponsive to antibiotic therapy.Clinical examination revealed a heart rate of 120/min, arespiratory rate of 20/min and a blood pressure of 110/80mmHg. Oral temperature was 37.5°C. His skin and con- junctiva were distinctly pale. The hemoglobin level was10 g/dl (age-adjusted reference range 11  –  16 g/dl) and thehematocrit was 30%. His height was 132 cm, and heweighed 28 kg. The lungs were clear on auscultation, andno heart murmur was detected. No organomegaly, lymph-adenopathy or rash was detected. Developmental historywas normal. Inspection of the mouth revealed a black round2×3-cm object on the right side of the posterior oropha-ryngeal wall (Fig. 1a). Blood was observed to ooze aroundthe object.The object was removed using with a blunt forceps after application of a topical anesthesia (lidocaine 10% spray).Removal was complete, and no part of the object was left  behind. Gross examination revealed an engorged live 6-cm-long leech (Fig. 1 b,c).Further questioning about the source of leech infestationrevealed a history of swimming in a lake near the village.Blood continued to ooze from the attachment site of theleech continued for almost 1 h after its removal. At the 1-week follow-up, the patient did not report any further episodes of hematemesis or leech in the pharynx. Review of the literature and discussion Leeches are carnivorous, hermaphrodite, segmented wormsthat belong to phylum Annelida, Class Hirudinea. Aquaticleeches can inhabit both fresh- and saltwater bodies, most commonly relatively still waters, sluggish streams and pad-dy fields, but there are also those that live on land. Leachescan vary from 5 to 15 cm in length. A leech has twosuckers, one at each end. The mouth lies within the anterior sucker. Blood-sucking species have jaws in the anterior sucker that contain chitinous teeth for biting. Hemophagicspecies engorge and darken during blood sucking [19].They may enter the body via the excretory openings of individuals who drink or bathe in infested waters, causingsubsequent internal hirudiniasis. [5, 10, 15] Reported sites of internal infestation include the nose[14], nasopharynx [3], larynx [11], vagina [8], urethra and Fig. 1 a  Engorged leech inoropharynx,  b  removed leech, c  closer view of the parasite40 Eur J Pediatr (2009) 168:39  –  42   bladder [12] and rectum [13]. The clinical picture is protean and depends mostly on the exact site of involvement. Thenose has been reported to be the most common site of involvement, and epistaxis is the most common signencountered [5, 7, 14]. Reported presentations of pharyn- geal hirudiniasis are sore throat, hematemesis, hemoptysis,sense of having a foreign body, dysphagia and melena.Laryngeal and hypopharyneal infestation may manifest asan emergency with signs of acute airway obstruction [1,11]. Anemia, which may be severe and even life-threaten-ing, is a common finding [5, 6]. Our patient experienced passive flow of fresh blood intothe oral cavity (without a history of vigorous coughing,epistaxis or gastrointestinal symptoms). To the best of our knowledge, this is the first reported case of leech en-doparasitism presenting in this manner. Painless loss of  blood into the oral cavity of our patient was the result of local analgesic substances secreted by the parasite and itssite of attachment at the posterior oropharynx. Differentialdiagnosis of this child ’ s condition includes nasopharyngeal pentastomiasis, which is caused by pentastomid larvae of the dog tongue worm,  Linguatula serrata . Larvae wander into the throat after the ingestion of infected raw sheep or goat liver or lymph nodes. This condition is locally called ‘ Halzoun ’  or   ‘ Marrara ’  in the Middle East and mainly presents with pain and itching of the throat and ears [17].Pharyngeal infection with  Fasciola hepatica  has also beenreported and should be included in the differential diagnosisof these patients [16].The strong attachment of the leech to the mucusmembrane combined with its soft and slippery body makeit difficult for the medical practitioner to get a good hold of the leech and remove it with force. If the leech is in thenares or upper pharynx, it can be paralyzed with cocaineand extracted directly. A hypertonic sodium chloridesolution or lidocaine can also be administered; the former causes the leach to release its hold, and the latter paralysesit [9, 19]. The leech can then be removed easily. Leech-induced infection is a documented complicationof both skin infestation and the therapeutic application of these organisms [2]. However, to the best of our knowl-edge, there is no report of such infectious complicationsfollowing internal infestations in the medical literature.A review of relevant articles published since 1980 inmajor medical databases (PUBMED, OVID, EBSCO,WILEY, SCOPUS and PROQUEST) using hirudiniasisand leech as keywords revealed a number of reported casesworldwide. These include cases from India (16), Pakistan(7), Middle east [Turkey (7), Israel (17),Saudi Arabia (2),Jordan (2), Iran (1), Oman (1), Syria (1)], Africa [Morocco(2), Kenya (1),Tanzania(1)] and the Far East [Malaysia (1),Indonesia (1), Japan (1), China (1)]. Spain was the onlyEuropean country for which we found cases (four) of thiscondition reported in the medical literature. Consideringthis vast geographical distribution and the low socioeco-nomic status and relatively low sanitation and healthcareservices of most of the countries reporting leech infection,the rarity of the condition seems to be a reflection of underdiagnosis rather than a true low prevalence.This report highlights the importance of consideringleech infestation and other types of parasitic pharyngitis as possible etiologies in pediatric patients presenting withhemoptysis, sore throat and anemia, especially in areas of  poor sanitation. Acknowledgments  Financial support for this study was provided bythe corresponding author. Conflict of interest statement  The authors of this article have noconflict or competing interests. All of the authors approved the finalversion of the manuscript. References 1. Al-Hadrani A, Debry C, Faucon F, Fingerhut A (2000) Hoarse-ness due to leech ingestion. J Laryngol Otol 114:145  –  1462. Ardehali B, Hand K, Nduka C, Holmes A, Wood S (2006)Delayed leech-borne infection with  Aeromonas hydrophilia  inescharotic flap wound. J Plast Reconstr Aesthet Surg 59(1):94  –  953. Bilgen C, Karci B, Uluoz U (2002) A nasopharyngeal mass: leechin the nasopharynx. Int J Pediatr Otorhinolaryngol 64(1):73  –  764. Connor NP, Conforti ML, Heisey DM, Vanderby R, Kunz D,Hartig GK (2002) Augmented blood removal after medicinalleech feeding in congested tissue flaps. J Rehabil Res Dev 39(4):505  –  5125. Cundall DB, Whitehead SM, Hechtel FO (1986) Severe anaemiaand death due to the pharyngeal leech  Myxobdella africana . TransR Soc Trop Med Hyg 80(6):940  –  9446. Demiroren K, Caliskan U (2003) Unexpected result in theetiological approaching to an anemic case: a leech infestation.Pediatr Hematol Oncol 20(7):547  –  5507. Gupta SC (1980) Nasal hirudiniasis in Kumaon Hills, India. TropGeogr Med 32(4):303  –  3058. Hernández M, Ramírez Gutierrez RE (1998) Internal hirudiniasis:vaginal bleeding resulting from leech bite. Ginecol Obstet Mex66:284  –  2869. Litch JA, Bishop RA (2000) Saturated aqueous sodium chloridesolution for the removal of leeches. Trop Doct 30:10210. Makiya K, Tsukamoto M, Horio M, Kuroda Y (1988) A casereport of nasal infestation by the leech,  Dinobdella ferox . J UOEH10(2):203  –  20911. Mohammad Y, Rostum M, Dubaybo BA (2002) Laryngealhirudiniasis: an unusual cause of airway obstruction and hemop-tysis. Pediatr Pulmonol 33(3):224  –  22612. Paul AK, Islam N (2005) Vesical hirudiniasis: an unusual causeof bleeding from the urethra. J Ultrasound Med 24(12):1731  –  173313. Raj SM, Radzi M, Tee MH (2000) Severe rectal bleeding due toleech bite. Am J Gastroenterol 95:160714. Rao KP, Grover YK, Mitra AK (1986) Nasal hirudiniasis. J IndianMed Assoc 84(2):55  –  56Eur J Pediatr (2009) 168:39  –  42 41  15. Raza SN, Shabbir SMA, Haq A (2006) Leech infestation and itsassociation with water drinking habits. J Coll Physicians Surg Pak 16(3):175  –  17816. Saba R, Korkmaz M, Inan D, Mamikoglu L, Turhan O, GunserenF, Cevikol C, Kabaalioglu A (2004) Human fascioliasis. ClinMicrobiol Infect 10(5):385  –  38717. Siavashi MR, Assmar M, Vatankhah A (2002) Nasopharyngeal pentastomiasis [Halzoun]: report of 3 cases. Iran J Med Sci 27(4):191  –  19218. Stephen L (1988) The medicinal leech. A page from the annelidsof internal medicine. Ann Intern Med 109:399  –  40519. White GB (1998) Leeches and leech infestation. In: Cook GC (ed)Manson ’ s tropical diseases, 20th edn. Saunders, London, pp 1523  –  152520. White TC, Berny MA, Robinson DK, Yin H, DeGrado WF,Hanson SR, McCarty OJ (2007) The leech product saratin is a potent inhibitor of platelet integrin alpha2beta1 and von Wille- brand factor binding to collagen. 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