This paper reports a case of prolonged bleeding following application of leeches to treat chronic pain. The paper discusses the characteristics of the wounds and possible complication of prolonged bleeding following medicinal leech application. The principles of treatment are also described.
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Both doctors and lay health practitioners use leeches of the phylum Annelida for therapeutic purposes in many countries worldwide. The medicinal leech, Hirudo medicinalis, is used for bloodletting and pain relief in traditional folk medicine, as well as by doctors to maintain local circulation after reimplantation, flap repairs, and breast and thoracic wall reconstructions. Complications related to leech bites are not commonly seen in emergency departments (ED). To date, only one patient with bleeding secondary to a leech bite, who received advice from an ED by phone, has been reported.1 Here we describe a patient who presented to the ED with prolonged bleeding from a leech bite, the first such report in the emergency medicine literature.
A 19 year old man presented to our ED complaining of bleeding from both legs. He had applied leeches to both legs at midnight to treat chronic leg pains of over a year’s duration. After the leeches spontaneously detached, he dressed his wounds and went to bed. When he woke up three hours later, he saw bloody bandages. The exact time of the onset of bleeding was unknown. As the bleeding did not stop in spite of compression and wrapping with tight bandages, he came to the ED at 8 45 am. He had no remarkable medical history.
On physical examination, he appeared generally healthy, was alert and oriented, and in no acute distress. Vital signs were as follows: blood pressure 110/80 mm Hg, heart rate 92 beats per minute, respiration rate 16 per minute, temperature 36 °C. Blood was oozing from two lacerations on his right leg, one 3 cm below and the other 4 cm medial to the tibial tuberosity. The distance between them was 7 cm. In addition, there were two lacerations on the lateral head of the gastrocnemius muscle on the left leg that had stopped bleeding. The distance between them was 5 cm. No ecchymosis, swelling, or erythema was present. His physical examination was otherwise normal. Laboratory findings were as follows: haemoglobin 18.1 g/dl, haematocrit 56%, mean corpuscular volume 98.1 femto l, white blood cells 6400/mm3, platelets 171 000/mm3, prothrombin time 13.48 seconds, activated partial thromboplastin time 35.3 seconds, and international normalised ratio 1.19. The peripheral blood smear was normal.
The wounds were rinsed with antiseptic solutions and bandaged with sterile gauze, following which he was observed in the ED for three hours. He was then discharged as no further bleeding had occurred. The wounds were unremarkable three days later, but the patient stated that the wounds had started oozing again one hour after discharge from the ED. When he had changed the dressings later that day, he had noticed clots on the wounds with bruising in the surrounding tissues, but there was no redness, warmth, or pain in the areas surrounding the wounds.
The medicinal leech has been used for medical purposes since at least 200 bc and is still used in Asia and Africa.1–3 A recent clinical study has reported that leech therapy may be an effective treatment for rapid reduction of pain associated with knee osteoarthritis.2 Our patient used leeches for alleviating pain and placed them at painful periarticular sites of the knee.
H. medicinalis has an approximately 10 cm long, cylindrical body with two suckers: one present anteriorly on the head, and the other on the posterior end. The mouth lies in the anterior sucker and has three jaws with teeth well designed for biting. The leech can ingest blood almost ten times its own weight (5–15 ml).1,3
Leech bites are painless and results in a triradiate wound which remains open for a long time and heals slowly1,3 (fig 1). The commonest complication of leech application is oozing, as was the case in our patient. The amount and duration of bleeding vary according to the area bitten, with bleeding from the vagina, rectum, urinary bladder, and pharynx having been reported.1,3,4 Prolonged haemorrhage may result in anaemia, and deaths from excessive exsanguination have been reported.3 In our patient, the bleeding continued for three hours and persisted intermittently for the next 18 hours, although he did not have any haematological problems. The mean duration of bleeding from leech bite wounds in one report was 10 hours (range 6.5–23).5
The saliva of the leech contains hirudin, which inhibits thrombin in the clotting process, and histamine-like substances which may cause continuous bleeding by preventing closure of capillaries.6 Munro et al reported that hirudin has only a transient antithrombin effect, lasting only about 15 minutes in humans. The prolonged duration of bleeding can be attributed to collagen–platelet interaction, along with possible modifications of the vascular walls by proteases or other enzymes secreted by the leech during feeding.5
Contamination with pathogenic microorganisms may result in erysipelas and submucosal abscesses.1,3 Leech application can also cause infection with Mycobacterium marinum, a parasitic bacteria usually hosted by salt water fish, or with Aeromonas hydrophilia, which leeches carry in their gut.7 As a medicinal leech bite heals, ecchymosis and scarring are not uncommon sequelae.1
As regards treatment, if the leech is still in place, it should be removed with the help of table salt, a saline solution, or vinegar. It should not be forcibly removed because its jaws may remain in the wound, causing infection.1 After removing the leech, pressure should be applied to the wound. If the bleeding persists, sterile gauze soaked in thrombin solution may be applied. After control of bleeding, the wound should be rechecked for signs of infection.1
In our patient, the leech had detached before arrival to the ED, and we had no thrombin solution to apply with the bandages. There was intermittent bleeding for an additional 18 hours. Leeches application in the evening or night should be avoided because bleeding cannot be noticed during sleep. Patients with bleeding disorders should not apply leeches to avoid prolonged bleeding. Emergency physicians should exercise caution when removing leeches, and they should not be surprised if patients present with persistent bleeding after removal.
I Ikizceli: data collection and drafting of the report. L Avşarogulları, E Sözüer: critical revision and drafting of the report. Y Yürümez, O Akdur: data collection and treatment and follow up of the patient during his admission and stay in the emergency department.
Competing interests: none declared
Patient consent was obtained.
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