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Table of Contents   
CASE REPORT
Year : 2011  |  Volume : 16  |  Issue : 4  |  Page : 155-157
 

Intraperitoneal leech: A rare complication of leech bite


Department of Paediatric Surgery, Guwahati Medical College, Guwahati, Assam, India

Date of Web Publication31-Oct-2011

Correspondence Address:
Manoj Saha
D-1, Asahdeep Tower, A. K. Azad Road, Rehabari, Guwahati, Assam - 781 008
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-9261.86877

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   Abstract 

An intraperitoneal leech, which entered through vagina and uterus in a 2-year-old girl is reported. The child presented with intraperitoneal hemorrhage and shock. A leech inside the peritoneal cavity has never been reported in the literature.


Keywords: Intraperitoneal leech, leech bite, vaginal leech bite


How to cite this article:
Saha M, Nagi S. Intraperitoneal leech: A rare complication of leech bite. J Indian Assoc Pediatr Surg 2011;16:155-7

How to cite this URL:
Saha M, Nagi S. Intraperitoneal leech: A rare complication of leech bite. J Indian Assoc Pediatr Surg [serial online] 2011 [cited 2017 Mar 25];16:155-7. Available from: http://www.jiaps.com/text.asp?2011/16/4/155/86877



   Introduction Top


In tropical regions, leech bites on the skin are commonly encountered, especially, when people walk carelessly through bushes and water. Vaginal leech bites, in children are also commonly heard in rural part of north-eastern India. Leeches have been reported in body cavities open to and nearer to the exterior. We report a 2-year- old girl with intraperitoneal leech. The leech entered her vagina and uterus, perforated the uterus and entered into the peritoneal cavity.


   Case Report Top


A 2-year-old female child presented with vaginal bleeding, abdominal distension, and shock following intrusion of a leech into her genitalia. According to her parents, while the child was playing in a waterlogged paddy field, they saw a leech entering into her genitalia. But before they could catch the leech, it entered inside. After that, they tried to expel the leech by indigenous method by inserting salt and herbs inside her vagina, but it was not successful. Then they took the child to nearby medical centre, where doctors tried to remove the leech by vaginal instrumentation. But that was also a failure. By that time the child developed abdominal distension and irritability. An ultrasonography of the abdomen showed hemoperitoneum with a moving worm (leech) inside the peritoneal cavity. Then the child was referred to us for further management.

When the child reached us, she was in a state of shock, with shrunken eyes, thready pulse, and abdominal distension with signs of peritonitis. Her hemoglobin was 7 gm/dl. The child was resuscitated with intravenous fluids. At laparotomy, 22 hours after the incident, the peritoneal cavity was full of blood, with blood clots in the pelvis. As soon as we started exploring, a tumid leech was found inside the peritoneal cavity, in the pool of blood [Figure 1]. Leech was caught by forceps and removed. At the time of surgery, the leech was dead, and it measured 10 cm in length [Figure 2].
Figure 1: Leech popping out from the pelvic cavity

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Figure 2: Postoperative leech specimen

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Then, blood was sucked out and the peritoneal cavity was washed with normal saline. There was a punched out perforation at the fundus of the uterus, through which the leech entered the peritoneal cavity, with oozing of blood from margins of the perforation. The uterus was also swollen. The perforation was repaired with 3-0 polyglactin suture. The bowel and mesentery were checked for leech bite injury. A corrugated drain was put into the pelvic cavity and the abdomen was closed. She received 350 ml of blood transfusion and broad spectrum antibiotics. The postoperative recovery was uneventful.


   Discussion Top


Leeches are invertebrates of phyllum Annelida and class Hirudinea. There are freshwater, terrestrial, and marine leeches. Some, but not all, leeches are hematophagus.

Hemophagic leeches attach to their host and remain there until they become full, at which point they fall off to digest the blood. A leech's body is composed of 34 segments. They all have an anterior (oral) sucker formed from the first six segments of their body, which is used to connect to host for feeding, and also release an anesthetic to prevent the host from feeling the leech. They use a combination of mucus and suctions (caused by concentric muscles in those segments) to stay attached to the host. Leech can suck and store blood up to ten times its body size. Leech's saliva contains hirudin (a potent antithrombin), histamine-like vasodilator, hyaluronidase, and calin (a platelet aggregation inhibitor). [1],[2],[3] Calin also inhibits platelet adhesion at the injured site. [4],[5] Bleeding from a leech bite wound can persist for a mean of 10 hours and as long as 7 days. [2]

In tropical region, leech bites of the skin are common events. However, serious consequence of leech bite injury to the internal viscera is uncommon. [6] But when it occurs, it can cause significant morbidity. Leech bite can cause epistaxis, [6],[7] hemoptysis, [8] hematemesis, [9] rectal bleeding, [10] and hematuria. [11] Leeches in different body cavities (e.g., urinary bladder, nasal cavity, pharynx and larynx) have also been reported. [11],[12],[13],[14] Leeches can enter maxillary sinus through the natural or a surgically created ostium. Kruger et al., [8] have reported vomiting of a leech in a 15-year- old girl.

Though vaginal bleeding due to leech bite is commonly encountered in the northeastern part of India (where authors belong), only few case reports are available in the world literature, [15],[16],[17],[18],[19],[20] of which only three reports are in children. [18],[19],[20] Aribarg et al., [19] from Bangkok have reported the largest series of 10 children with vaginal bleeding due to leech bite. In their report, nine cases were diagnosed by a history of leech dropping out of the vagina, accompanied by vaginal bleeding. There was only one case where the leech was actually found in the vagina during examination. In our case the leech entered the vagina and uterus, perforated the uterus, and entered into peritoneal cavity. Perforation of uterus and intraperitoneal leech has not been reported earlier. To our knowledge, this is the first report of visceral perforation by a leech. The morbidities associated with leech bite are mainly due to two factors - mechanical obstruction of a vital organ, [21] and/or severe bleeding. [8],[16] Our case is unique, because of combination of severe bleeding associated with visceral perforation.

Leeches normally carry parasites in their digestive tract, which cannot survive in human and do not pose a threat. However, bacteria, viruses, and parasites from previous blood sources can survive within a leech for months, and may be transmitted to human. A study found both HIV and hepatitis-B in African leeches from Cameroon. [22] These facts pose threat particularly at the time of detaching the leech from the victim. When detachment is tried, either by chemicals or by pulling it by surgical forceps, the leech tends to regurgitate its stomach contents into the wound. Therefore, after removal or detachment of the leech, the wound should be thoroughly cleaned with soap and water.

 
   References Top

1.Adams LA. The emergency management of a medicinal leech bite. Ann Emerg Med 1989;18:316-9.  Back to cited text no. 1
    
2.Munro R, Hechtel FO, Sawyer RT. Sustained bleeding after a leech bite in the apparent absence of hirudin. Thromb Haemost 1989;61:366-9.  Back to cited text no. 2
[PUBMED]    
3.Conforti ML, Connor NP, Heisey DM, Hartig GK. Evaluation of performance characteristics of the medicinal leech (Hirudo medicinalis) for the treatment of venous congestion. Plast Reconstr Surg 2002;109:228-35.  Back to cited text no. 3
[PUBMED]  [FULLTEXT]  
4.Munro R, Jones CP, Sawyer RT. Calin - A platelet adhesion inhibitor from the saliva of the medicinal leech. Blood Coagul Fibrinolysis 1991;2:179-84.  Back to cited text no. 4
[PUBMED]    
5.Deckmyn H, Stassen JM, Vreys I, Van Houtte E, Sawyer RT, Vermylen J. Calin from hirudo medicinalis, an inhibitor of platelet adhesion to collagen, prevents platelet-rich thrombosis in hamsters. Blood 1995;85:712-9.  Back to cited text no. 5
[PUBMED]  [FULLTEXT]  
6.Bergua A, Vizmanas F, Monzon FJ, Blasco RM. Unavoidable epistaxis in the nasal infection of leeches. Acta Otorhinolaringol Esp 1993;44:391-3.  Back to cited text no. 6
    
7.Ghimire A, Acharya A. Unusual cause of unilateral epistaxis: Nasal leech infestation. J Nepal Med Assoc 2008;47:38-40.  Back to cited text no. 7
    
8.Kruger C, Malleyeck I, Olsen OH. Aquatic leech infestation: A rare cause of severe anemia in an adolescent Tanzanian girl. Eur J Pediatr 2004;163:297-9.  Back to cited text no. 8
    
9.El-Awad ME, Patil K. Haematemesis due to leech infestation. Ann Trop Paediatr 1990;10:61-2.  Back to cited text no. 9
    
10.Raj SM, Radzi M, Tee MH. Severe rectal bleeding due to leech bite. Am J Gastroenterol 2000;95:1607.  Back to cited text no. 10
[PUBMED]  [FULLTEXT]  
11.Deka PM, Rajeev TP. Unusual cause of hematuria. Urol Int 2001;66:41-2.  Back to cited text no. 11
[PUBMED]  [FULLTEXT]  
12.none Satyawati, Singhal SK, Dass A. Multiple live leeches from nose in a single patient - A rare entity. Indian J Otolaryngol Head Neck Surg 2002;54:154-5.  Back to cited text no. 12
    
13.none Bilgen C, Karci B, Uluöz U. A nasopharyngeal mass: Leech in the nasopharynx. Int J Pediatr Otorhinolaryngol 2002;64:73-6.  Back to cited text no. 13
    
14.none Uygur K, Yasan H, Yavuz L, Dogru H. Removal of a laryngeal leech: A safe and effective method. Am J Otolaryngol 2003;24:338-40.  Back to cited text no. 14
    
15.none Katsulov A. A leech in the vaginal wall of an elderly woman causing hemorrhage. Akush Ginekol (Sofiia) 1968;7:379-80.  Back to cited text no. 15
    
16.Hailemariam B. Post menopausal vaginal bleeding due to vaginal wall leech infestation. Ethiop Med J 1995;33:183-5.  Back to cited text no. 16
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17.Hernandez M, Ramirez Gutierrez RE. Internal hirudiniosis: Vaginal bleeding resulting from leech bite. Ginecol Obstet Mex 1998;66:284-6.  Back to cited text no. 17
    
18.none Ibrahim A, Gharib HB, Bidin NM. An unusual cause of vaginal bleeding: A case report. Int J Gynecol Obstet 2003. Available from: http://www.ispub.com/ostia/index.php?xmlFilePath=journals/ijgo/vol2n2/leech.xmlnone . [last accessed on 2011 Feb 5].  Back to cited text no. 18
    
19.Aribarg A, Phupong V. Vaginal bleeding in Thai children due to leech. J Trop Med Parasitol 1999;22:77-9.  Back to cited text no. 19
    
20.none Saha PK, Roy S, Bhattacharya D, Mukherjee P, Naskar T, Bhuiya A. Leech bite: A rare gynecologic emergency. Med Gen Med 2005;7:73.   Back to cited text no. 20
    
21.Solomon E. Leech-an unusual cause of (laryngo-tracheal) obstruction. Ethiop Med J 1991;29:141-2.  Back to cited text no. 21
[PUBMED]    
22.Nehili M, Ilk C, Mehlhorn H, Ruhnau K, Dick W, Njayou M. Experiments on the possible role of leeches as vectors of animal and human pathogens: A light and electron microscopy study. Parasitol Resnone 1994;80:277-90.  Back to cited text no. 22
    


    Figures

  [Figure 1], [Figure 2]


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