A case series of bleeding due to Leech infestation from the Gimbie region,Ethiopia

Case 1

A 2-year-old boy, with normal weight-for-age (10 kg) presented to Gimbie Adventist Hospital (GAH) with a story of one week of night fever. His presenting complaints were melanea and haematemesis. On examination he was alert, pale, tachycardic with no signs of respiratory distress, with normal skin turgor and capillary refill time. His temperature was 37.8° Celsius. Abdominal examination was normal, no tenderness or hepatosplenomegaly was found. Laboratory examination revealed a haemoglobin of 3.3 g/dL, haematocrit 10, white blood cell count 14.3×10⁹/L and a negative blood film for malaria parasites. He was transfused with 300 mL of whole blood and started on empirical intravenous (i.v.) quinine despite an initial negative malaria film. Ampicillin and chloramphenicol i.v. were commenced as disseminated intravascular coagulopathy, was suspected secondary to sepsis or Plasmodium falciparum infection, we considered a viral haemorrhagic fever and the child was isolated. The night of admission he vomited fresh blood on four occasions. Next day, he became apyrexial and vomited up a leech; subsequently the vomiting stopped. Haemoglobin estimation remained stable, i.v. quinine was stopped and he received fansidar stat and oral ranitidine. Recovery was uneventful. On questioning, it was discovered that he was breast-fed but also drank water from the local river, which had not been boiled.

Case 2

A 22-year-old woman presented in the GAH community clinic with a two-week history of profuse vaginal bleeding. The patient was a virgin. Her periods occurred regularly every 28 days and she normally bled for 5 days. There was no history of menorrhagia. Prior to being seen at our clinic she had received ergometrine and ampicillin from the local pharmacy without benefit. On examination, she was weak and pale, her pulse, temperature and blood pressure were normal. System examination was unremarkable. Vaginal examination revealed a leech in the periclitoral region of the perineum. Bimanual examination and Cusco's speculum examination were normal. The leech was removed and the bleeding stopped. The woman reported that she usually bathed in the local river.

Case 3

A 2-year-old boy presented to GAH with his parents. The presenting complaint was that he had swallowed a leech while bathing in the local river. The patient was otherwise asymptomatic. All observations were stable. On examination of the oral cavity a leech was seen attached to the posterior pharynx, behind the uvula. An attempt was made to remove it with a forceps. However, while trying to remove it the leech moved more distally in the posterior pharynx and attempts to remove it were abandoned. The boy was scheduled to return a few days later and the leech was removed under direct vision with a forceps. Recovery was uneventful.

Discussion

Leeches are commonly used at many microsurgical and plastic surgery units to provide essential venous outflow for compromised tissues. The saliva of leeches contain an anticoagulant and a histamine-like vasodilator that promote local tissue bleeding as well as a local anaesthetic and a hyaluronidase that promote the local spread of the leech saliva. Their controlled use in medical practice is useful, but they can also damage tissues.

Many reports have been published on leech infestation. They can affect any organ system that has a natural anatomical portal of entry, i.e. the nasopharynx and urogenital system. Ocular leech infections have been reported which are associated with swimming in streams. ¹ The presenting symptoms are varied depending on the organ system involved – stridor and cough in the larynx; ² epistaxis for intranasal or nasopharyngeal infestation; ³ haematuria in bladder infestation; ⁴ and vaginal bleeding in genital infestation.^5,6

In a resource poor setting it can be difficult to determine the cause of bleeding, as in our first case. In endemic regions, the diagnosis of bleeding secondary to leech infestation should always be considered. The appropriate treatment involves the mechanical removal of the leech under direct vision. All patients should also have broad-spectrum antibiotic cover, as leech infestation is associated with systemic infection, Aeromonas hydrophilia and Serratia marcescens are the most common infecting agents. ⁷ Primary prevention should be encouraged in endemic regions, all drinking water should be boiled and filtered and, after bathing, a search for any leeches should be undertaken.

There have been isolated reports in Ethiopia of bleeding due to leech infestation.^5,6 The implications of leech infestation are underestimated and they can be life threatening. Making health-care workers aware of this endemic disease will lead a quicker diagnosis and the application of the appropriate treatment.