Uncommon cause of airway obstruction and hypovolemic shock: pharyngeal leech infestation in a rural Ethiopian child

Abstract

Leech infestation of the upper airway is an uncommon but potentially life-threatening condition, especially among children living in rural areas with limited access to safe drinking water. Early recognition and intervention are crucial to prevent severe complications such as airway obstruction and profound anemia.

We present the case of an 8-year-old boy from rural North Gondar, Ethiopia, who arrived at our facility with a 5-day history of coughing up blood, blood-stained saliva, hoarseness, throat discomfort, and progressive respiratory distress. On examination, he was acutely ill, severely anemic (hemoglobin 4.0 g/dL), and in hypovolemic shock. A dark, mobile foreign body was visualized in the oropharynx. Due to the unavailability of laryngoscopy, the leech was manually extracted with MaGill forceps at the bedside. The patient received blood transfusions and antibiotics, resulting in rapid clinical improvement and an uneventful recovery.

Oropharyngeal and laryngeal leech infestations, while rare, are important considerations in children from endemic regions presenting with unexplained upper airway symptoms and anemia. The parasite’s anticoagulant and anesthetic secretions can delay symptom onset and diagnosis, increasing the risk of morbidity. Limited resources often hinder optimal management, but prompt recognition and removal of the leech are essential for a favorable outcome.

This case highlights the importance of heightened clinical awareness of leech infestations in at-risk populations. Public health measures to improve water, sanitation, and community education are vital to prevent future cases in resource-limited settings.

Introduction

Leech infestation of the upper airway is a rare but potentially life-threatening condition, most commonly seen in children residing in rural areas of tropical and subtropical regions, where untreated water sources are frequently consume^[1,2^]. Ingestion of contaminated water allows leeches to attach to the mucosal surfaces of the oropharynx or larynx, leading to symptoms such as hemoptysis, throat discomfort, airway obstruction, and severe anemia[3]. Early recognition is crucial, as delayed diagnosis can result in significant morbidity and mortality. Although only a handful of cases of oropharyngeal leech infestation have been reported in Ethiopia, the increasing number of case reports highlights the ongoing risk in resource-limited settings^[4,5^]

HIGHLIGHTS

• Leech infestation of the upper airway is a rare but potentially life-threatening condition.

• Children living in these tropical and subtropical are particularly susceptible, largely due to the regular consumption of unfiltered water.

• This case unique is its presentation and management way.

(Table 1). Here, we present a case of pharyngeal leech infestation in an 8-year-old boy from rural North Gondar, Ethiopia, emphasizing the clinical challenges of diagnosis and management in such environments. We have compared similar case reports around our area as table (Table 1). The work has been reported in line with the SCARE criteria[6].

Table 1.

Summary of reported leech infestation cases from ethiopia and related settings.

Author/Year	Title/Source	Patient Profile	Site of infestation	Key presentation	Hb/Severity	Management	Outcome
Shitaye & Shibabaw, 2017	Severe anemia due to pharyngeal leech infestation (Case report)	Child	Pharynx	Hematemesis, anemia	Severe	Endoscopic removal + transfusion	Recovered
Duffy, 2008	Case series of bleeding due to leech infestation (Gimbie region)	Multiple rural patients	Oropharynx/nasopharynx	Recurrent bleeding	Variable	Manual extraction	Good outcomes
IMCRJ, 2021	Leech infestation causing severe anemia in a 10‑month‑old infant	Infant	Oropharynx	Severe anemia, bleeding	Marked	Removal + transfusion	Recovered
Gibrie et al., 2025	Oropharyngeal leech infestation in a 65‑year‑old male	Adult	Oropharynx	Dysphagia, bleeding	Severe anemia	Endoscopic removal	Recovered
Akale et al., 2025	Leech infestation – rare cause of upper GI bleeding	Adult	Upper GI tract	GI bleeding	Moderate	Endoscopy + removal	Recovered
Case Report (High‑output HF)	Unexpected culprit: High‑output heart failure induced by severe anemia from laryngeal leech infestation	Adult	Larynx	Severe anemia, dyspnea, high‑output heart failure	Profound anemia	Leech removal + transfusion + supportive care	Recovered
North Gondar Study, 2022	Dynamics of leech infestation in livestock and control practices	Livestock population	External & mucosal	Infestation burden	—	Control practices	Epidemiologic relevance
Present case (current report)	Pharyngeal leech causing airway obstruction & hypovolemic shock	8‑year‑old child	Oropharynx/airway	Hemoptysis, airway obstruction, shock	Hb 4.0 g/dL	Manual removal withou laryngoscopy + transfusion	Full recovery

Case presentation

An 8-year-old boy presented to our surgical emergency outpatient clinic with a 5-day history of coughing up blood, frequent spitting of blood-tinged saliva, and a persistent sensation of something stuck in his throat. The above symptoms got worsened for the last 1 day. He also complained of hoarseness, worsening shortness of breath when lying down, fatigue, blurred vision, and dizziness. Notably, he did not experience throat pain, nosebleeds, black stools, or any recent trauma. He had been diagnosed with acute tonsillopharyngitis at a local health center and prescribed amoxicillin, but his symptoms did not improve. His condition worsened, with increasing fatigue and difficulty breathing, prompting his referral to our facility. The patient resides in a rural area of North Gondar, Ethiopia, and regularly consumes untreated spring water.

On arrival, the boy appeared acutely ill, with a heart rate of 140 beats per minute which is feable, a respiratory rate of 34 breaths per minute, a temperature of 36°C, and an oxygen saturation of 90% on room air. Examination of his mouth revealed blood-stained mucosa involving the oropharynx, palate, and tongue. A dark, mobile foreign body was seen in the oropharynx, surrounded by signs of inflammation, though his vocal cords remained mobile. He also had pale conjunctivae. Cardiovascular assessment revealed a systolic ejection murmur and capillary refill goes slowly. His abdominal examination was unremarkable. He has cold extremity and decreased level of consciousness. Lab tests showed a white blood cell count of 14 000, hemoglobin of 4.0 g/dL, and platelet count of 250 000.

Given his clinical presentation and examination findings, we suspected hypovolemic shock secondary to acute blood lose secondary to a pharyngeal leech infestation with air way compromisation. As flexible fibreoptic laryngoscopy was unavailable at our center, we performed a manual throat examination supported by MaGill forceps and spatula. The diagnosis of pharyngeal leech infestation was strongly supported.

The patient underwent immediate resuscitation and hemodynamic stabilization. After taking informed consent from his families, a bedside removal of the foreign body with MaGill forceps was performed, successfully extracting a live, actively moving leech (as shown in Fig. 1 and Supplemental Digital Content video 1, available at: http://links.lww.com/IJSCR/A18 and Supplemental Digital Content video 2, available at:. http://links.lww.com/IJSCR/A19, inserted as Video). After removal, gauze was applied to the attachment site to stop bleeding, and any accumulated hematoma was cleared. Further inspection of the laryngeal area revealed no other abnormalities. He received four units of whole-blood transfusion and was started on ceftriaxone. His recovery was uneventful, and he was discharged on the fifth day post-procedure with advice to avoid drinking untreated spring water and to consume iron-rich foods.

Figure 1.

(A and B) Dark, mobile leech after bedside extraction.

Discussion

Laryngeal leech infestation, though uncommon, is a clinically important condition that can result in potentially fatal airway obstruction^[1,7^]. These parasites are more prevalent in tropical and subtropical climates, meaning cases are more frequently seen in rural areas of Africa, Asia, and South America. Children living in these regions are particularly susceptible, largely due to the regular consumption of unfiltered water^[2,8^]. In Ethiopia, report of oropharyngeal leech infestation is rare^[1,5,9,10^]. What make this case unique is its presentation and management way. Additionally, there is only one such case reported in north-eastern part of Ethiopia, which is appeared just in this year, 2025, indicating rising prevalence of this disease in this region and call for further research and need for public health interventions focused on improving water sanitation in these regions to prevent such infestations^[1,4,11^].

After entering the body, the leech attaches itself to the mucosal lining of the respiratory or digestive tract, including areas such as the larynx. It then releases an anticoagulant called hirudin, which prevents blood from clotting and enables the leech to feed undetected for a prolonged period[3]. The saliva of the leech also contains anesthetic substances, which further delay the appearance of symptoms. As a result, patients may initially experience no symptoms or only mild complaints, such as a sensation of something stuck in the throat, coughing, or difficulty swallowing^[1,12^]. However, as the leech feeds and grows larger, it can cause increasing obstruction, leading to more pronounced symptoms such as hoarseness, difficulty breathing, coughing up blood, and, in severe cases, airway blockage[13]. Reports from Sudan and Ethiopia highlight that delayed diagnosis can lead to serious complications, including severe anemia from ongoing blood loss^[4,14^]. These findings underscore the necessity of prompt identification and treatment.

Laryngoscopy remains the gold standard for diagnosing laryngeal leech infestation, as it enables direct visualization of the parasite. Radiographic imaging, on the other hand, is seldom helpful in identifying the leech itself but can be valuable for excluding other potential causes of airway obstruction, such as foreign bodies or tumors[13]. Once the diagnosis is confirmed, definitive management involves removal of the leech. One of the safest techniques is performing the extraction under general anesthesia delivered by face mask, without the use of an endotracheal tube. This approach, typically carried out with the aid of laryngoscopy or endoscopy, ensures that the entire leech is carefully and completely removed[15]. Special caution is necessary during removal, as leaving behind any part of the leech – particularly the head or sucker – may lead to persistent bleeding or secondary infection^[13,16^].

Following prompt removal of the leech, appropriate post-procedural care is essential. Antibiotics are commonly administered to prevent secondary infections, and corticosteroids may be given to help minimize inflammation at the site[13]. In instances of substantial blood loss, as reported in cases from Ethiopia and Tanzania, blood transfusions might be required to treat resulting anemia. With proper management, recovery after leech removal is usually smooth, and patients often experience rapid improvement in their symptoms once the parasite is extracted^[2,17^].

Since we are in resource limited setting, there was no functional laryngoscopy available. Our patient was managed with manual removal of the leech with MaGill forceps. He was given bold products and broad-spectrum antibiotics and was followed for 5 days for possible post procedural complication.

Conclusion

This case underscores the importance of considering leech infestation as a differential diagnosis in children presenting with unexplained upper airway symptoms and severe anemia, particularly in rural, resource-limited regions where untreated water is commonly consumed. Early recognition and prompt removal of the leech are vital to prevent life-threatening complications such as airway obstruction and profound blood loss. Additionally, this report highlights the challenges faced in low-resource settings, where diagnostic and therapeutic options may be limited. Public health measures aimed at improving access to safe water, coupled with community education about the risks of consuming untreated water, are essential for preventing such cases. Continued reporting and awareness are needed to guide clinical suspicion and inform future interventions in endemic areas.

Ethical approval

This case report is exempt from the requirement of ethical approval.

Consent

Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.

Sources of funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Conflicts of interest disclosure

None

Author contributions

K.T.Y.: management of the patient, wrote the original draft, and revision of the final manuscript; M.H.S.: Writing – original draft, Conceptualization; B.A.A.: Writing – review & editing; A.A.Z.: Writing – review & editing, Resources; B.T.M. and B.A.T.: Writing – review & editing.

Guarantor

Dr. Kinfemicheal Tilahun Yigzaw, MD.

Research registration unique identifying number (UIN)

Not applicable.

Provenance and peer review

Not applicable.

Data availability statement

Not applicable.

Acknowledgements

Not applicable.