Nasopharyngeal hirudiniasis,a rare cause of masked hemoptysis in an older patient: A case report

Introduction

Leeches are annelids related to earthworms. Medicinal species (family Hirudinidae) feature “jaws” with calcified teeth that are used to pierce the skin and extract blood or lymph. Large genera such as Hirudo, Macrobdella, and Haemadipsa grow to lengths between 5 and 20 cm, making them powerful enough to feed on mammals, including humans. ¹ Although medicinal leeches are extensively used in reconstructive and microsurgical procedures, accidental infestation of the upper aerodigestive tract remains rare and may lead to nasopharyngeal hirudiniasis, a condition associated with diagnostic challenges in otolaryngology practice. ²

Clinical manifestations of hirudiniasis are primarily related to the pharmacological effects of leech saliva, which contains a potent thrombin inhibitor that prevents coagulation and sustains bleeding. ³ Consequently, patients may present with nonspecific symptoms, including unexplained hemoptysis or a foreign body sensation, which can mimic more common otolaryngologic conditions, thereby leading to delayed diagnosis. ⁴

We report a case of nasopharyngeal hirudiniasis in a 62-year-old male presenting with persistent hemoptysis. This case underscores the necessity of considering parasitic infestation in the differential diagnosis of unexplained upper airway bleeding, particularly in individuals with a history of exposure to untreated freshwater.

Case presentation

A male in his early 60s who was a non-smoker and had a history of well-controlled hypertension presented with a 2-week history of persistent hemoptysis associated with pharyngeal discomfort. He denied fever, hoarseness, epistaxis, dyspnea, or other respiratory symptoms. The patient had initially been evaluated at Al-Salmuni hospital in Masyaf, Syria, where no definitive diagnosis had been established, and referral for specialist assessment was recommended.

On clinical examination, his vital signs were normal. Oropharyngeal inspection revealed a transient, mobile structure within the pharynx that rapidly disappeared from view, raising suspicion of a mobile blood clot or foreign body. Flexible nasopharyngoscopy subsequently demonstrated a moving foreign body attached to the nasopharyngeal wall.

After elevating the uvula to improve visualization, the foreign body was successfully grasped and removed using curved forceps without anesthesia. The extracted organism was identified as a leech measuring approximately 3 cm in length (Figure 1). The dynamic movement and physical characteristics of the parasite were documented immediately after extraction (Video 1).

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Figure 1.

Macroscopic appearance of the extracted parasite.

The patient experienced immediate resolution of symptoms following removal.

Patient history taken after extraction revealed consumption of untreated pond water approximately 3 weeks prior to presentation, suggesting ingestion of the parasite through contaminated water. A diagnosis of nasopharyngeal hirudiniasis was established based on clinical findings, endoscopic visualization, and exposure history. Following the procedure, the patient was prescribed a prophylactic course of oral amoxicillin/clavulanate (1 g twice daily) for 7 days to prevent secondary bacterial infection at the site of leech attachment. The patient was followed up 2 weeks after the extraction; he remained asymptomatic with no recurrence of bleeding or complications. The reporting of this case report conforms to the Case Report (CARE) guidelines. ⁵

Discussion

Nasopharyngeal hirudiniasis is an uncommon condition that often presents a diagnostic challenge in otolaryngology. Hirudo medicinalis is an aquatic parasitic annelid commonly found in freshwater environments that does not typically cause infestation in individuals who have not undergone leech therapy. In patients without prior therapeutic exposure, infestation may occur through accidental ingestion or mucosal contact with contaminated water sources, a route of transmission that remains rare and infrequently reported in the medical literature. ⁶

The biological properties of Hirudo medicinalis play a significant role in the clinical masking of this condition. Leech saliva contains several bioactive substances, including local anesthetics and hirudin, which allow painless attachment and promote persistent bleeding by inhibiting coagulation. ⁷ Consequently, nasopharyngeal hirudiniasis often presents with nonspecific symptoms that overlap with more common systemic or localized conditions, leading to considerable diagnostic delay. In the present case, the patient’s age and prolonged hemoptysis initially raised concerns regarding pulmonary, cardiovascular, or malignant etiologies. Furthermore, the patient’s residence in a rural area near Masyaf, Syria, where exposure to untreated freshwater sources is common, underscores a critical epidemiological risk factor that was initially overlooked. Interestingly, despite these environmental conditions, no similar case of nasopharyngeal hirudiniasis has been previously reported in this specific geographical area, highlighting the rarity and clinical significance of this presentation. As reported in the literature, hemoptysis in older patients frequently prompts extensive evaluation for neoplastic and cardiopulmonary causes, which may obscure less common parasitic infestations. ⁸ In this case, chest computed tomography (CT) imaging was deferred because the source of bleeding was directly identified using nasopharyngoscopy. Given the immediate resolution of symptoms post-extraction and the clear environmental history, further radiological investigations were deemed unnecessary, thereby preventing unnecessary expenditure and radiation exposure for the older patient.

The anatomical location of the infestation generally correlates with clinical manifestations. In this patient, the absence of hoarseness or inspiratory stridor suggested that the parasite was confined to the nasopharynx and had not progressed to the glottic level where airway compromise would be expected. ⁹ Diagnostic evaluation in such scenarios is particularly challenging due to the anatomical characteristics of the nasopharynx, which represents a relative blind area during routine clinical examination. Blood originating from the nasopharynx may drain toward the larynx and trigger a cough reflex, thereby misleading clinicians to focus on the lower respiratory tract rather than the upper airway. ¹⁰

The mechanical resistance encountered during extraction was attributable to the strong attachment of the leech’s anterior and posterior suckers. The immediate cessation of bleeding following removal confirmed that the hemorrhage was primarily related to the parasite’s anticoagulant secretions rather than to structural mucosal injury.

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