Leech Bite: A Rare Gynecologic Emergency

Abstract

Vaginal bleeding as the result of a leech bite is a rare occurrence. We report 2 cases of vaginal bleeding in young girls that resulted from a leech bite and required treatment. Clinical presentation and management for young girls is described. Health professionals working in rural areas where leech infestation is common should be aware that children are at risk for leech bites in the genital region; a high index of suspicion is of great help to make an early diagnosis and ensure prompt treatment.

Introduction

Vaginal bleeding as the result of a leech bite is very rare. There are only 3 case reports available in the Medline-indexed literature.[1–3] Vaginal bleeding in young girls as the result of a leech bite has not been reported before in the indexed literature, although the case of a 9-year-old was reported by Malaysian researchers in an online journal in 2003.[4] We managed 2 cases of vaginal bleeding caused by leech bite at our hospital. A description of their presentation and management, along with a review of the literature, are presented.

Case 1

A 5 -year-old tribal girl presented with a sudden episode of vaginal bleeding 2 hours following a bath in a pond. When she presented to our hospital (approximately 7 hours after the onset of symptoms), her general condition was stable except for tachycardia (pulse rate 110/min) and mild pallor. Her hemoglobin was 9.5 gm%. There was no history of trauma, pain; nor was there evidence of abuse. As the patient was bleeding, she was taken for examination under anesthesia (EUA). The vagina was explored with a nasal speculum and a leech was found at the posterior wall of vagina at the junction of the middle and lower thirds. The leech was removed by plain forceps. The size of the leech bite wound was approximately 0.5 × 0.5 cm and was red in appearance without any edema. The vagina was packed with a betadine-soaked gauze as there was active bleeding from the posterior wall of the vagina at the site of the leech bite. The pack was removed after 20 hours. Ampicillin was given for 3 days. The patient was discharged on the third postoperative day in satisfactory condition. The patient was in good health when she came for a follow-up exam 1 week after the postoperative period.

Case 2

A 7-year-old girl had similar history of vaginal bleeding after taking her bath in a small river. There was no history of trauma or pain. She first went to a primary health center, from which she was referred to our Medical College; she arrived at about 14 hours after the onset of the symptoms. The patient's mother gave the history of possible leech bite as it was common in their area. The patient had marked pallor and tachycardia (pulse rate 120/min). Her hemoglobin was 7.5 gm%. After arranging 1 unit of blood, EUA was performed. No apparent cause could be ascertained but she continued to bleed. A normal saline wash of vagina was performed via a small feeding tube. A black leech came out from the vagina. The site of bleeding was found to be in the left lower half of the vagina at about 3 cm above the introitus. It measured approximately 0.5 × 1.0 cm. There was no edema or swelling at this site. A small betadine-soaked pack was put inside the vagina and removed after 18 hours. The patient also received 1 unit of blood (200 mL). She was discharged after 48 hours in good condition. Ampicillin was given for 3 days. There was no complaint when she came back for follow-up exam 10 days after the postoperative period.

Discussion

Leeches are invertebrates of phylum Annelida and class Hirudinea. A leech is usually about 12.5-15.25 mm long.[5] In tropical regions, leech bites on the skin are a common event. However, serious consequences of leech bite injury to the internal viscera are uncommon.[6] If they do occur, they can cause significant morbidity and may even be fatal.[6,7] Leech bite to various sites (eg, the nose, pharynx, larynx, esophagus, rectum, and bladder) have been reported sporadically in the literature.[6–10] Vaginal bleeding due to a leech bite is even more rare. We have found only 4 case reports available in the world literature, one of which involved a child.[1–4]

The morbidity associated with a leech bite is mainly due to 2 factors – mechanical obstruction of a vital organ and/or severe bleeding, as in our cases.

The prolonged bleeding after a leech bite is due to the action of factors in the leech saliva left in the bite, which include histamine-like vasodilators, hirudin (a potent antithrombin), hyalurondinase, and calin (a platelet aggregation inhibitor).[11–13] Interaction between exposed collagen and platelet and/or von Willebrand factor is believed to be one of the initiating events for thrombus formation at the site of damaged endothelium. Interference with this mechanism may provide an antithrombotic potential. Calin specifically inhibits human platelet aggregation induced by collagen.[14] In addition, it has been shown that calin inhibits platelet adhesion.[14,15] Bleeding from a leech bite wound can persist for a mean of 10 hours and as long as 7 days.[3,12] Indeed, medicinal leeches are used to treat venous congestion because of their ability to remove excess blood and temporarily increase blood flow within compromised tissue.[13]

A case of vaginal bleeding following a leech bite was first published in the Bulgarian literature[1] in 1968. We have found only 3 other case reports in the world literature. One case report, published in the Ethiopian Medical Journal in 1995,[2] describes a 50-year-old woman (para 6) who was referred to a hospital with postmenopausal bleeding with hemorrhagic shock to rule out endometrial carcinoma. Speculum examination revealed a darkish mass attached to the posterior vaginal fornix, and this was found to be a leech. In another case, reported in the Spanish literature in 1998, a postmenopausal woman presented with continuous bleeding per vaginum for 7 days, after a swim in the river.[3] Gynecologic examination revealed that the cause of bleeding was a leech bite, and the leech was removed with surgical forceps. A case report of a vaginal leech bite in a 9-year-old girl from Kelantan, Malaysia, published in the online Internet Journal of Gynecology and Obstetrics,[4] was recently brought to our attention, and the case bears resemblance to ours – although our treatment protocol was slightly different.

A leech bite can be diagnosed simply on the basis of patient history and examination. Our patients were very young children, however, and without anesthesia it would have been difficult to perform a gynecologic examination. If a leech is found and is still in place, it should be removed with the help of table salt, a saline solution, vinegar, or lignocaine solution.[2,11]

In our second case, saline solution was applied. Removal of a leech by surgical forceps or by endoscopic biopsy forceps has also been reported in the literature.[3-5,9] In parous women, simple speculum examination without anesthesia and removal of a leech by surgical forceps from vagina is a management option.[2,3] Care should be taken during removal of a leech using surgical forceps, however. The leech should not be forcibly removed because its jaws may remain in the wound, causing continuous bleeding and infection.[16] If the patient continues to bleed after removal of the leech, pressure should be applied to the wound with sterile gauze soaked in thrombin solution.[16] There have been case reports describing the use of electrocoagulation to stop bleeding from the lesion in leech bite.[9,10] Suturing the lesion has not been recommended. As thrombin solution was not available to us, we applied betadine-soaked gauze pieces in both of these cases to reduce the possibility of infection. There are no data to support the use of any systemic drugs that alter the coagulation. However, desmopressin (DDAVP) has been reported to attenuate the bleeding caused by continuous hirudin infusion in rabbits.[17] Bleeding from a leech bite can be severe, requiring blood transfusion, and it can produce shock.[2,8,10] As there was significant bleeding in the second case, the patient required a blood transfusion of 1 unit.

Vaginal bleeding due to a leech bite is rare. A high index of suspicion is of great help in making the correct diagnosis at an early stage and thus reducing morbidity. Care should be taken during removal of a leech with surgical forceps. We emphasize that if one has doubt as to whether vaginal bleeding in a child is due to a leech bite, the vagina can be washed with normal saline through a small catheter, because speculum examination is difficult in young children. The parasite should come out as normal saline causes irritation and dislodges the parasite from the vagina. To date there is no recommendation to administer any systemic hemostatic drugs to stop bleeding. We believe that one should not try to suture the bite site as bleeding is due to alteration of coagulation at the local site. Simple packing with betadine should serve the purpose well.

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