Leech Bite


Article Author:
Kara Conley


Article Editor:
Andrew Juergens


Editors In Chief:
Venkat Minnaganti
John Brusch
Janak Koirala


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Frank Smeeks
Kristina Soman-Faulkner
Radia Jamil
Patrick Le
Sobhan Daneshfar
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Pritesh Sheth
Hassam Zulfiqar
Navid Mahabadi
Steve Bhimji
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Mark Pellegrini
James Hughes
Beata Beatty
Nazia Sadiq
Hajira Basit
Phillip Hynes
Tehmina Warsi


Updated:
3/9/2019 9:45:48 PM

Introduction

Leeches are hermaphroditic parasites of phylum Annelida and class Hirudinea. There are over 600 species of leeches. A minority of these are sanguinivorous and the cause of human morbidity. Historically, leeches have been used for medicinal purposes with the earliest recorded being 1500 BC. Leeches have continued to be used throughout history and most recently have been used in modern medicine primarily for reconstructive surgery. Leeches live by ingesting blood or bodily fluid. [1][2][3]An adult leech can ingest 1 milliliter per minute of blood, and the area of attachment can bleed for 10 hours to as long as 7 days in some instances. Land leeches can penetrate thick skin, while aquatic leeches attach to mucous membranes leading to prolonged bleeding.

Etiology

Leach bites may be due to swimming or bathing in leach infested waters or by deliberate placement for reconstructive surgery.

Epidemiology

Limited information is reported regarding leech bites, and the majority of case reports are from the tropics or subtropics and occur after contact with fresh water. Vaginal leech bites in children are reported commonly in rural north-eastern India. [4][5][6][7]Sanitation advances have led to decreased incidence of nasal leech infestation in developed nations. In one review of six patients with nasal leeches, all patients had been in rural streams 2 weeks to 2 months before symptoms occurred.

Pathophysiology

Leech bites primary occur while bathing or drinking unfiltered water or while swimming in contaminated water. A leech has an anterior oral sucker as well as a posterior sucker. The anterior sucker is used for feeding. The leech releases an anesthetic on attachment to the host to prevent the host from recognizing the parasite is attached. Due to contents of saliva, leech wounds can bleed longer than a typical wound, causing morbidity.

Toxicokinetics

Leech saliva contains numerous substances including hirudin (potent antithrombin), hyaluronidase, histamine-like vasodilator, and calin (a platelet aggregation inhibitor). Hirudin from leech saliva can take hours to wear off. It is a peptide which inhibits the thrombin-catalyzed conversion of fibrinogen into fibrin clots and remains active for 15 to 20 minutes.[8] Leech attachment sites may bleed more than normal wounds and can continue to bleed after removal of the leech.

History and Physical

A detailed history needs to be obtained, including any recent exposure to fresh water. While most leech bites are external, leeches can attach internally, and patients will present with epistaxis, hematemesis, hemoptysis, vaginal bleeding, hemoptysis, otorrhagia, and rectal bleeding. When the leech bite is external, patients' symptoms may include painless bleeding, bruising, itching, burning, irritation, and redness. Patients may present with recurrent epistaxis if they have a nasal leech infestation. 

A focused physical exam will be required depending on the area of concern. If there is a concern for a nasal leech infestation, examination with anterior rhinoscope is not sufficient, and inspection with an endoscope is usually necessary. When there is the concern for vaginal leech infestation, a speculum exam is required. Depending on the age of the patient, this may need to be done under anesthesia. A rectal exam with a proctoscope may be indicated for a patient presenting with rectal bleeding in the setting of concern for a leech bite.

Evaluation

Most leech bites will not significantly alter coagulation pathways, although case reports do exist where prothrombin (PT) and partial thromboplastin time (PTT) times were affected. If there is a concern for a significant amount of bleeding, a complete blood count (CBC) may be obtained. Leech attachments can cause significant bleeding leading to acute blood loss anemia. Imaging typically is not necessary as the leech is often found on physical exam. However, if suspicion remains for a leech infestation imaging of the area of concern may be necessary. One case report discussed the presentation and treatment of an intraperitoneal leech which was seen on abdominal ultrasound and another report described a leech which was seen over the left nasal cavity on computed tomography (CT) scan.

Treatment / Management

Initial treatment should include removal of the leech or leeches, controlling blood loss, and preventing exposure to blood-borne pathogens.

Various methods of leech removal have been utilized including salt, saline, vinegar, turpentine, alcohol, and heat. Chemical methods have also been used including cocaine, lidocaine, and topical anesthetic spray. Of these, saltwater has been shown to be effective in causing the leech to relax and release. Extra caution should be used when removing the leech as to not have reflux of contents back into the bite for risk of infection as well as increased bleeding. [9][10][11]Caution should be exercised to prevent the jaws from remaining in the wound for risk of continuous bleeding.

Leech removal often requires unique situational removal techniques based on the location of the leech. A 2-year-old was found to have an intrabdominal leech which had perforated her uterus, and it required exploratory laparotomy for removal. A case report discussed a 24-year-old male with a leech bite in the external ear canal near the tympanic membrane with bleeding from the ear. Lidocaine 2%, then hypertonic saline was placed into the ear without decreased movement of the leech. Next, glycerin phenique was placed into the ear. The movement of the leech decreased, and the bleeding ceased after 4 hours. After the bleeding had stopped, the leech was removed with alligator forceps. When trying to remove a leech from the vagina of a pediatric patient, normal saline flushed through a small feeding catheter has been reported with success.

After removing the leech, the wound must be cleaned, and bleeding must be stopped. Betadine or topical antibiotic agents can be used to clean the wound. A hemostatic agent or bandage can be used in addition to a pressure dressing to help with hemostasis. Cauterization, local application of tranexamic acid, silver nitrate, suturing of wounds, and tampon use have all be described as methods for achieving hemostasis after a leech bite. Case reports exist where blood product infusions have been required. Tranexamic acid has also been used to achieve hemostasis.

Complications

Leeches are carriers of viruses and bacteria. HIV and Hepatitis C were isolated from live leeches pulled from fishermen in Africa. Viruses may remain in leeches for as long as 5 months. Studies have also shown that malaria is capable of replicating in the red blood cells that a leech ingests. Leeches carrying infectious diseases have also been found in medicinal leeches with reports of 2.4% to 20% infection rate during medicinal leech therapy. The majority of these infections were caused by Aeromonas hydrophila which can be treated with fluoroquinolones, although resistant strains exist. It may be reasonable, after weighing risks and benefits, to offer the patient antibiotics after a leech bite.

Deterrence and Patient Education

Prevention of leech bites includes avoiding leech infested areas and wearing clothing that covers the lower extremities. If swimming in a potential leech-infested pond, wear tight-fitting swimwear. Insect repellents such as N, N-diethyl-meta-toluamide or N, N-diethyl phenylacetamide have also been suggested.

Enhancing Healthcare Team Outcomes

The management of leech bites is with a multidisciplinary team that includes an emergency department physician, nurse practitioner, primary care provider, and an infectious disease consultant. There are many methods of removing leeches and overall the outcomes are excellent.[12] 

However, leeches are known to carry a variety of viruses and bacteria that may cause a systemic infection. The decision to treat the patient with antibiotics requires good clinical judgment. The key is to educate travelers on how to prevent leech bites. This may be done by wearing appropriate clothing while in the water and using insect repellants. [12]


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Leech Bite - Questions

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A 17-year-old male presents with epistaxis. It is described as a slow ooze from the right nostril. Yesterday, he went with some friends to a local freshwater pond where he went swimming and "mud wrestling." He experienced no trauma to the face, but did have some abrasions to his legs from branches and did have to remove some leeches. Physical exam, including anterior rhinoscopy, does not reveal a source of bleeding. However, a small amount of unclotted blood is noted coming from the right nare. What is the next step in management?



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A 3-year-old female presents after spending the day at the lake with her family. She has a leech on her leg. After it is removed, there is persistent slow bleeding. What is the next step in management?



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What is the etiology of prolonged bleeding after a leech bite, even after the parasite is removed?



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A 17-year-old male presents with erythema of his left lower extremity localized around an area where a leech bit him 1-day prior. Antibiotics are needed. What class of antibiotic should be prescribed?



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A 17-year-old-male presents with complaint of epistaxis that started after swimming in a rural stream earlier in the day which has been known to have leeches. On arrival, his vital signs are within normal limits and exam is notable for bleeding from the right nare. On closer inspection, a leech is seen in the anterior right nare. What is the next step in management?



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Leech Bite - References

References

Joslin J,Biondich A,Walker K,Zanghi N, A Comprehensive Review of Hirudiniasis: From Historic Uses of Leeches to Modern Treatments of Their Bites. Wilderness     [PubMed]
El Boussaadni Y,Babakhouya A,Amrani R,Rkain M,Benajiba N, [Leeches: An unusual cause of epistaxis in children]. Presse medicale (Paris, France : 1983). 2017 May;     [PubMed]
Øregaard JS,Lang CL,Venzo A, Partial salvage of avulsed tissue after dog bite. Annals of the Royal College of Surgeons of England. 2016 Feb;     [PubMed]
Karunaratne AH,Wijerathne BT,Wickramasinghe RS,Wijesinghe AK,Liyanage AS, A Rare Case of Vaginal Bleeding in a Child Due to a Leech Bite and Review of the Literature. Wilderness     [PubMed]
Momeni A,Parrett BM,Kuri M, Using an unconventional perfusion pattern in ear replantation-arterialization of the venous system. Microsurgery. 2014 Nov;     [PubMed]
Rasi A,Faghihi A,Jalali MA,Zamanian A,Ghaffarpour G, Leech therapy for epidermoid cysts and review of the literature. Advanced biomedical research. 2014;     [PubMed]
Buote NJ, The use of medical leeches for venous congestion. A review and case report. Veterinary and comparative orthopaedics and traumatology : V.C.O.T. 2014;     [PubMed]
Seiverling EV,Khalsa A,Ahrns HT, Pruritis and palpable purpura from leeches in the Australian Rainforest. IDCases. 2014;     [PubMed]
Wiwanitkit V, ENT bleeding and leech bite. Advanced biomedical research. 2013;     [PubMed]
Lok U,Bozkurt S,Okur M,Gulacti U,Hatipoglu S, A rare case of adverse effects caused by leech bite. The American journal of case reports. 2013;     [PubMed]
Askari N,Eshaghian A, Otorrhagia bleeding due to leech bite. Advanced biomedical research. 2012;     [PubMed]
Concannon MJ,Puckett CL, Microsurgical replantation of an ear in a child without venous repair. Plastic and reconstructive surgery. 1998 Nov;     [PubMed]

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