Intraperitoneal leech: A rare complication of leech bite.

An intraperitoneal leech, which entered through vagina and uterus in a 2-year-old girl is reported. The child presented with intraperitoneal hemorrhage and shock. A leech inside the peritoneal cavity has never been reported in the literature.

INTRODUCTION

In tropical regions, leech bites on the skin are commonly encountered, especially, when people walk carelessly through bushes and water. Vaginal leech bites, in children are also commonly heard in rural part of north-eastern India. Leeches have been reported in body cavities open to and nearer to the exterior. We report a 2-year- old girl with intraperitoneal leech. The leech entered her vagina and uterus, perforated the uterus and entered into the peritoneal cavity.

CASE REPORT

A 2-year-old female child presented with vaginal bleeding, abdominal distension, and shock following intrusion of a leech into her genitalia. According to her parents, while the child was playing in a waterlogged paddy field, they saw a leech entering into her genitalia. But before they could catch the leech, it entered inside. After that, they tried to expel the leech by indigenous method by inserting salt and herbs inside her vagina, but it was not successful. Then they took the child to nearby medical centre, where doctors tried to remove the leech by vaginal instrumentation. But that was also a failure. By that time the child developed abdominal distension and irritability. An ultrasonography of the abdomen showed hemoperitoneum with a moving worm (leech) inside the peritoneal cavity. Then the child was referred to us for further management.

When the child reached us, she was in a state of shock, with shrunken eyes, thready pulse, and abdominal distension with signs of peritonitis. Her hemoglobin was 7 gm/dl. The child was resuscitated with intravenous fluids. At laparotomy, 22 hours after the incident, the peritoneal cavity was full of blood, with blood clots in the pelvis. As soon as we started exploring, a tumid leech was found inside the peritoneal cavity, in the pool of blood [Figure 1]. Leech was caught by forceps and removed. At the time of surgery, the leech was dead, and it measured 10 cm in length [Figure 2].

Figure 1

Leech popping out from the pelvic cavity

Figure 2

Postoperative leech specimen

Then, blood was sucked out and the peritoneal cavity was washed with normal saline. There was a punched out perforation at the fundus of the uterus, through which the leech entered the peritoneal cavity, with oozing of blood from margins of the perforation. The uterus was also swollen. The perforation was repaired with 3-0 polyglactin suture. The bowel and mesentery were checked for leech bite injury. A corrugated drain was put into the pelvic cavity and the abdomen was closed. She received 350 ml of blood transfusion and broad spectrum antibiotics. The postoperative recovery was uneventful.

DISCUSSION

Leeches are invertebrates of phyllum Annelida and class Hirudinea. There are freshwater, terrestrial, and marine leeches. Some, but not all, leeches are hematophagus. Hemophagic leeches attach to their host and remain there until they become full, at which point they fall off to digest the blood. A leech's body is composed of 34 segments. They all have an anterior (oral) sucker formed from the first six segments of their body, which is used to connect to host for feeding, and also release an anesthetic to prevent the host from feeling the leech. They use a combination of mucus and suctions (caused by concentric muscles in those segments) to stay attached to the host. Leech can suck and store blood up to ten times its body size. Leech's saliva contains hirudin (a potent antithrombin), histamine-like vasodilator, hyaluronidase, and calin (a platelet aggregation inhibitor).[1-3] Calin also inhibits platelet adhesion at the injured site.[45] Bleeding from a leech bite wound can persist for a mean of 10 hours and as long as 7 days.[2]

In tropical region, leech bites of the skin are common events. However, serious consequence of leech bite injury to the internal viscera is uncommon.[6] But when it occurs, it can cause significant morbidity. Leech bite can cause epistaxis,[67] hemoptysis,[8] hematemesis,[9] rectal bleeding,[10] and hematuria.[11] Leeches in different body cavities (e.g., urinary bladder, nasal cavity, pharynx and larynx) have also been reported.[11-14] Leeches can enter maxillary sinus through the natural or a surgically created ostium. Kruger et al.,[8] have reported vomiting of a leech in a 15-year- old girl.

Though vaginal bleeding due to leech bite is commonly encountered in the northeastern part of India (where authors belong), only few case reports are available in the world literature,[15-20] of which only three reports are in children.[18-20] Aribarg et al.,[19] from Bangkok have reported the largest series of 10 children with vaginal bleeding due to leech bite. In their report, nine cases were diagnosed by a history of leech dropping out of the vagina, accompanied by vaginal bleeding. There was only one case where the leech was actually found in the vagina during examination. In our case the leech entered the vagina and uterus, perforated the uterus, and entered into peritoneal cavity. Perforation of uterus and intraperitoneal leech has not been reported earlier. To our knowledge, this is the first report of visceral perforation by a leech. The morbidities associated with leech bite are mainly due to two factors - mechanical obstruction of a vital organ,[21] and/or severe bleeding.[816] Our case is unique, because of combination of severe bleeding associated with visceral perforation.

Leeches normally carry parasites in their digestive tract, which cannot survive in human and do not pose a threat. However, bacteria, viruses, and parasites from previous blood sources can survive within a leech for months, and may be transmitted to human. A study found both HIV and hepatitis-B in African leeches from Cameroon.[22] These facts pose threat particularly at the time of detaching the leech from the victim. When detachment is tried, either by chemicals or by pulling it by surgical forceps, the leech tends to regurgitate its stomach contents into the wound. Therefore, after removal or detachment of the leech, the wound should be thoroughly cleaned with soap and water.