Case Reports International - Journal for publishing high quality case reports
 
  Table of Contents    
Case Report
 
A rare cause of hemoptysis: Leech infestation
Ben Ghezala Hassen1, Snouda Salah2, Ferchichi Samia3, Abbes Fehmi4, Bechikh Imen2
1Medical Director Physician Director, Teaching Department of Emergency and Intensive Care Medicine, Zaghouan Hospital, Zaghouan, Tunisia.
2Medical Director, Teaching Department of Emergency AND Intensive Care Medicine,Zaghouan Hospital, Zaghouan, Tunisia.
3Medical Director, Department of Pneumology, Zaghouan Hospital, Zaghouan, Tunisia.
4Medical Director, Department of Cardiology, Zaghouan Hospital, Zaghouan, Tunisia.

Article ID: 100008CRINTBH2015
doi:10.5348/crint-2015-8-CR-3

Address correspondence to:
Snouda Salah
Regional Hospital of Zaghouan
Avenue of Environment, Zaghouan1100
Tunisia
Phone: +216 90269364
Fax: +216 72675772

Access full text article on other devices

  Access PDF of article on other devices

[HTML Abstract]   [PDF Full Text] [Print This Article]
[Similar article in Pumed] [Similar article in Google Scholar]

How to cite this article:
Hassen BG, Salah S, Samia F, Fehmi A, Imen B. A rare cause of hemoptysis: Leech infestation. Case Rep Int 2015;4:11–13.


Abstract
Introduction: Hemoptysis is a medical emergency. Unusual causes may exist. We report a very rare case of hemoptysis, whose cause has proven an infestation of the respiratory mucosa by a Leech.
Case Report: An 80-year old male presented with a three-day history of hemoptysis. The patient was admitted to our intensive care unit for respiratory distress and hemodynamic instability. Endoscopic examination was performed following nasal packing under local anesthesia and oxygen. A worm was noticed adhered to the bronchial mucosa. This worm was removed under local anesthesia and identified as a leech.
Conclusion: The infestation by the leech remains relatively rare. The diagnosis should be considered in the presence of unexplained hemoptysis, in patients with a recent history of drinking stream water. Endoscopy is the cornerstone in the diagnosis and the treatment of this infestation.

Keywords: Bronchial mucosa, Bronchiectasis, Hemoptysis, Leech, Tuberculosis


Introduction

Hemoptysis is a medical emergency. Patients die from asphyxiation or exsanguination. The most common causes are tuberculosis, bronchiectasis, and carcinoma [1]. But "unusual" causes may exist. When hemoptysis is massive or associated with respiratory failure, the patient should be supported in intensive care unit. We report a very rare case of hemoptysis, poorly tolerated hemodynamically, whose cause has proven an infestation of the respiratory mucosa by a blood-sucking worm: "A leech"!


Case Report

An 80-year old male presented with a three-days history of hemoptysis. He had a history of prostate adenoma and tobacco. Clinical examination revealed a body temperature of 37.4°C, a heart rate of 120/min, a blood pressure of 80/ 60 mmHg, a respiratory rate of 24/min, oxygen saturation of 90%. The pulmonary auscultation objectified few wheezing. Arterial blood gas analysis revealed hypoxemia and respiratory alkalosis. Chest radiography showed a bilateral bronchial syndrome. The hemoglobin level was 8 g/dl. The patient was admitted to our intensive care unit for respiratory distress and hemodynamic instability. He was put on oxygen and adrenaline aerosol without improvement. Endoscopic examination was performed following nasal packing under local anesthesia and oxygen. A worm was noticed adhered to the bronchial mucosa. This worm was removed under local anesthesia and identified as a leech. It was black in color, measured about 4 cm and was mobile (Figure 1). After removal of the leech, bleeding stopped immediately with spectacular stabilization of respiratory and hemodynamic status.


Cursor on image to zoom/Click text to open image
Figure 1: The leech.



Discussion

Leeches are blood-sucking hermaphroditic parasites belonging to the phylum Annelida of the class Hirudinea [2]. Leeches are generally found in puddles of water and streams. The contamination occurs by drinking infected water, and then, leeches localize on the mucus of pharynx, tonsils, esophagus, nose or nasopharynx, trachea, lower genitourinary tract (urethra and vagina), rarely in larynx and even eyes [3]. They feed on the blood of its hosts by biting through the skin and sucking out a quantity of blood equivalent to 890% of their body weight. They secrete anticoagulants such as hirudin, which inhibits thrombin and factor IXa, and hementerin, a plasminogen activator [4]. Symptoms depend on the localization place of the leech. They may causes epistaxis and nasal obstruction if they attache the nasal cavity and nasopharynx. If the leech is found in the oral cavity, the symptoms include hemoptysis and a feeling of a foreign body inside the mouth. The localization of the leech in the larynx causes symptoms like hemoptysis, hoarseness and respiratory distress [5]. Leeches may causes gastrointestinal bleeding and severe anemia, which may require a blood transfusion [6] . In some cases the hemoptysis may be responsible for respiratory distress and hemodynamic instability, as was the case in our patient. Endoscopy is the key examination to confirm the diagnosis and the treatment is based on the instrumental delivery of the leech. This extraction is not always easy, firstly because of its location, on the other hand due to its important link power. When the leech is found attached to the respiratory tract, it may be easily removed by using forceps. We must be very careful while removing the leech from its location; because of its slippery body surface which can easily be ruptured [7]. In our case, leech was removed safely in one piece by using forceps with the requirement of local anesthesia. Treatment involves thereafter, antiseptic and local analgesics as well as the treatment of anemia, present in almost half of cases [8].


Conclusion

The infestation by the leech remains relatively rare. The diagnosis should be considered in the presence of unexplained hemoptysis, in patients with a recent history of drinking stream water. Endoscopy is the cornerstone in the diagnosis and the treatment of this infestation. To avoid contamination, people living in rural areas should be informed of the complications resulted by such ectoparasites and should use natural spring water after boiling and filtering them.


References
  1. Harrison TR, Braunwald E. Hemoptysis. In: Harrison's Principles of internal medicine. 15th ed. New York: McGraw-Hill 2001:203–6.    Back to citation no. 1
  2. Guerrant RL, Walker DH, Weller PF. Essentials of tropical infectious diseases. Philadelphia: Churchill Livingstone; 2001. p. 607–8.    Back to citation no. 2
  3. EbrahimRazi. Aquatic leech infestation: A rare cause of hemoptysis. Case Rep ClinPract Rev 2007;8:125–27.    Back to citation no. 3
  4. al-Hadrani A, Debry C, Faucon F, Fingerhut A. Hoarseness due to leech ingestion. J Laryngol Otol 2000 Feb;114(2):145–6.   [CrossRef]   [Pubmed]    Back to citation no. 4
  5. Ismail I, Ozgur S, Imran S, Ferhat B, Mehmet TG. A Rare Cause of Epistaxis, Hemoptysis and Anemia: Leech in the Nasopharynx. J Med Cases 2010;1:71–3.    Back to citation no. 5
  6. White GB. Leeches and leech infestation, In: Cook GC, Manson's Tropical Diseases. 20th ed. London: Saunders; 1998. p. 1523–5.    Back to citation no. 6
  7. O.zdek A, Emir H, Kaptan ZK. An Unusual Cause of Adult Dyspnea and Hemoptysis: Leech Infestation of the Larynx. Journal of Ear Nose Throat and Head Neck Surgery 2008;16:138–40.    Back to citation no. 7
  8. Şengül E, Bakir S, Şengül CA, Erdur Ö. An unusual cause of epistaxis, anemia and upper respiratory tract obstruction Leeches: Report of three cases. J ClinExp Invest 2012;3:401–3.    Back to citation no. 8

[HTML Abstract]   [PDF Full Text]

Author Contributions
Ben Ghezala Hassen – Substantial contributions to conception and design, Acquisition of data, Analysis and interpretation of data, Drafting the article, Revising it critically for important intellectual content, Final approval of the version to be published
Snouda Salah – Analysis and interpretation of data, Revising it critically for important intellectual content, Final approval of the version to be published
Ferchichi Samia – Analysis and interpretation of data, Revising it critically for important intellectual content, Final approval of the version to be published
Abbes Fehmi – Analysis and interpretation of data, Revising it critically for important intellectual content, Final approval of the version to be published
Bechikh Imen – Analysis and interpretation of data, Revising it critically for important intellectual content, Final approval of the version to be published
Guarantor of submission
The corresponding author is the guarantor of submission.
Source of support
None
Conflict of interest
Authors declare no conflict of interest.
Copyright
© 2015 Ben Ghezala Hassen et al. This article is distributed under the terms of Creative Commons Attribution License which permits unrestricted use, distribution and reproduction in any medium provided the original author(s) and original publisher are properly credited. Please see the copyright policy on the journal website for more information.



  Home line About the Journal line Aim and Scope line Sections line Open Access line Archives
Apply as Editor line Apply as Reviewer line Submit Reviews - Editors line Submit Reviews - Reviewers
Instructions for Authors line Templates to Use line Copyright Form line Author Checklist
Online Submission line Email Submission line Submit Revision line Submit All Forms line Submit Page Proofs
Terms of Service line Privacy policy line Disclaimer line FAQ line Contact: Journal line Contact: Edorium Journals line Site Map
 
  Copyright © 2015. Edorium. All rights reserved.