Nasal leech infestation causing persistent epistaxis.

Foreign bodies in the nasal cavity are commonly encountered as a cause of epistaxis; however, nasal leech infestation as a cause of unilateral persistent epistaxis is very rare. Examination of nasal cavity revealed fleshy material in the left nostril, which was identified as leech. The leech was removed with the help of an artery forceps following irrigation of the left nostril with normal saline and adopting wait-and-watch policy. In developing countries, leech infestation as a cause of epistaxis should be suspected in patients with lower socioeconomic status or in those living in rural areas who give history of drinking polluted water from, or bathing in, stagnant ponds and puddles.

INTRODUCTION

Foreign bodies constitute an uncommon cause of unilateral epistaxis in children. Various inanimate and animate foreign bodies have been commonly found; however, nasal leech infestation as a cause of epistaxis is very uncommon, and only a few cases have been reported till date. Leech endoparasitism is extremely rare in urban areas but is frequent in endemic rural areas.[1] Leech infestation has also been reported to result in severe anemia requiring blood transfusion.[2] Sometimes patients with nasal leech infestation may have persistent epistaxis which may be difficult to control. One such case presenting with persistent epistaxis is reported below.

CASE REPORT

A 7-year-old girl presented to the emergency room at the rural health center with history of nasal stuffiness for 4 weeks along with history of persistent bleeding from the left nostril for 3 days which frequently soaked her handkerchief in the form of small drops. She gave history of marked irritation in the left nostril, associated with difficulty in breathing when right nostril was occluded. She complained of having a sensation of a moving object in the left nostril and was repeatedly picking her left nostril. She had been prescribed xylometazoline nasal drops and oral pseudoephedrine; however, these did not result in improvement. She did not give history of inserting any foreign body in the nostril, fever, runny nose or similar episodes of epistaxis in the past. Physical examination revealed that the child was in agony and was crying with pain. Her pulse rate was 96/min and blood pressure was 126/74 mm Hg. She had pallor, and fresh blood was persistently oozing from the left nostril. Local pressure did not help in controlling the epistaxis.

Examination of the nasal cavity revealed a soft fleshy material bulging into the left nostril close to the inferior turbinate. Attempt was made to pull it out with the help of an artery forceps; however, being a slimy structure, it repeatedly slipped from the grip of artery forceps and appeared to be tightly stuck to the inferior turbinate. After making a few attempts, the lower part of this fleshy material could be disentangled, and it was found to be moving. At this stage, it was identified as leech infesting the left nostril. Since repeated attempts to dislodge the leech by artery forceps failed, irrigation of the left nostril with normal saline was done and it was decided to wait and watch. After a few minutes, it could be easily dislodged with the help of artery forceps. The leech was still alive and was 8 cm long [Figure 1]. After a few minutes, the bleeding from the left nostril also decreased. Left nostril was packed with gauze piece. The child was given oral decongestant tablets, oral amoxicillin and intramuscular tetanus toxoid. Hematological investigations revealed hemoglobin to be 7.6 g/dL; and total leukocyte count, 9,800/mm3. Examination of external auditory canal did not reveal any evidence of leech infestation. After the procedure, she informed that she belonged to a very low socioeconomic stratum of society and had no access to safe drinking water and had to drink polluted water from an open pond and also take bath in it. Nasal packing was removed the next day, and the child became completely asymptomatic. She was advised not to take bath in polluted stagnant ponds or drink water from the open ponds. She was also advised to report immediately to the emergency department if similar complaints arose.

Figure 1

The leech after removal from the nasal cavity

DISCUSSION

Orificial hirudiniasis is a condition in which a leech enters the body orifices, most often the nasopharyngeal region; however, some cases of leeches infesting the urethra, vagina, rectum or even eyes have been reported. Leeches are blood-sucking hermaphroditic parasites that attach themselves to the vertebrate hosts, bite through the skin and suck out blood. Common species that infest humans are Dinobdella ferox, Hirudinea granulosa and Hirundinea viridis. Both aquatic and land leeches are known to attack humans. Leeches have gained fearsome reputation by feeding externally on blood, often from human hosts. Infestation occurs by drinking infested water from, or taking bath in, stagnant streams, pools and springs.

Leech infestation may cause serious complications like airway obstruction, severe respiratory distress, hemoptysis or hematemesis.[3] Leeches attach to the tissue by two muscular suckers, use three teeth inside their anterior sucker for biting and blood is sucked into stomach by peristalsis. Leeches can ingest large amounts of blood into their stomach, which may weigh 8 to 9 times their body weight, and may cause severe anemia in the host.[4] Because leech bites are painless, infestation may remain symptomless until a warning sign appears. Epistaxis, nasal obstruction and sensation of a moving foreign body are common presenting complaints of leech infestation in the nose. The saliva of leech contains hirudin, which inhibits thrombin in the clotting process; and histamine-like substances cause continuous bleeding by causing vasodilatation.

Leech infestation primarily occurs in tropical areas such as Mediterranean countries, Africa and Asia.[1] Cases of nasal leech infestation have been reported from various parts of India,[5] Pakistan[6] and Nepal.[7] Direct removal of leech might be difficult because of its powerful attachment to the nasal mucosa and its slimy and mobile body.[8] Various innovative techniques have been used for treatment of nasal leech infestation. These include a) anterior rhinoscopy along with suction; and b) wait-and-watch policy — water is taken in a kidney tray and placed with water level 1 cm below nasal vestibule. In a comparative study of these two methods of treatment of nasal leech infestation, the method involving a wait-and-watch policy was found to be a better technique.[7] As soon as leech is seen coming out from the nasal vestibule towards the water, it is caught with artery forceps and gently pulled out. The removal is faster with the former technique; however, it is associated with more bleeding and pain. The method involving a wait-and-watch policy is a better technique and causes less pain and less blood loss, but it is more time consuming. Besides this, various substances can be used to tranquilize leech before removal. Irrigation with strong saline, vinegar, turpentine oil or alcohol may be used for removal of leech.[9] It can also be detached by applying 30% cocaine, 1:10,000 adrenaline or dimethyl phthalate.[10]

CONCLUSION

Leech endoparasitism as a cause of nasal stuffiness and epistaxis is very rare. Due to the presence of anticoagulant in the saliva of leech, bleeding may be persistent. Because the nasal cavity is not readily visualized, rhinoscopy is generally required for diagnosis; however, it may not be possible in an emergency setup, as in our case. Hence high index of suspicion is required in a patient presenting with unilateral epistaxis who gives history of drinking polluted water from, or bathing in, ponds and puddles.