Diagnostic dilemma in a case of a leech in the upper aerodigestive tract.

Sir,

A 48-year-old lady hailing from a rural area in east Sikkim presented to us in June 2002, with complaints of breathlessness and dry cough for two-and-a-half months and crawling sensation in the throat for two months. The patient gave a history of hemoptysis three days prior to presentation. There was no history of fever, weight loss, dysphagia, melena, nasal bleeding or drug abuse. There was no history of similar episodes in the patient earlier. The patient had previously been managed at another hospital. She was diagnosed as a case of bronchial asthma, and treated with steroids and bronchodilators (Salmeterol and Fluticasone combination spray and Salbutamol spray) for two months, with no response. Examination at this institute revealed fresh blood over the soft palate. Indirect laryngoscopy and nasal examination were normal. Chest auscultation revealed crepitus in the right middle zone of the lungs. There was no pallor discernible over the tongue or conjunctiva.

A chest roentgenogram revealed non-homogenous opacities in the right paracardiac and basal lung parenchyma suggesting pneumonitis [Figure 1]. Neck roentgenograms, serum hemoglobin, total and differential leukocyte counts, and the coagulation profile were also normal. However, these findings did not explain the crawling sensation in the throat. The patient was therefore, subjected to fiberoptic laryngoscopy under local anesthesia. A black moving object was noticed in the trachea. This was suspected to be either a leech or blood clot. It was decided not to proceed further under local anesthesia. Post procedure, the patient confirmed the habit of drinking water directly from streams with cupped hands. The next day, the patient was subjected to fiberoptic bronchoscopy under general anesthesia. A leech was observed in the trachea at a distance of 17 cm from the upper incisor teeth. The leech was removed alive by the suction pressure of the fiberoptic bronchoscope [Figure 2].

Figure 1

X-ray Chest posteroanterior view was unremarkable

Figure 2

The leech extracted from the trachea

Postoperative recovery of the patient was uneventful. The crawling sensation and breathlessness had resolved the same evening. Hemoptysis was not reported after the procedure. The cough subsided within seven days of the procedure. The chest roentgenogram was normal on the seventh day.

Leeches in the upper aerodigestive tract have been frequently reported in literature. They are known to occur as a consequence of drinking leech-infested water with cupped hands, a habit frequently found in the local population in Sikkim.[12] Leeches can cause respiratory distress because of narrowing of the airway.[3] Epistaxis and hemoptysis occur on account of failure of the blood to clot because of hirudin. Although the bleeding is minor, it may lead to anemia.[4] In the current case, the diagnosis was not suspected on presentation. Similar diagnostic dilemmas have been frequently reported.[5] Once the diagnosis is established, the treatment is straightforward. It has generally been recommended that leeches in the upper aerodigestive tract should be removed endoscopically with a forceps after tranquilizing them, as they can be slippery.[4] However, in the current case the leech was removed by suction. This ensured complete removal.