Oropharyngeal leech infestation as a cause of severe anemia in a 65-year-old male patient: a case report

Abstract

Background

Leech infestations are rare but potentially serious medical conditions, often leading to hemorrhage and anemia. Leeches, which belong to the phylum Annelida and class Hirudinea, typically infest humans through contact with contaminated water or ingestion of unfiltered water. They attach to the mucosa of the aerodigestive tract, causing bleeding, and in severe cases, complications such as airway obstruction or severe anemia. Leech infestations are more prevalent in rural areas with limited access to safe water, where environmental conditions facilitate exposure.

Case presentation

We presented the case of a 65-year-old male farmer  of Amhara ethnicity from a rural area in North Wollo, Ethiopia, who experienced spitting blood-tinged saliva for 2 weeks. He also reported a foreign body sensation in his throat, lightheadedness, and difficulty speaking. The symptoms started after he drank water from a spring commonly used for livestock. Upon examination, the patient appeared pale and had a dark brown cylindrical leech attached to the posterior wall of his oropharynx, along with clotted blood. The patient was first found at his home during home-to-home medical care by a mobile medical team. This case represents a rare instance of esophageal bleeding caused by a single leech infestation, which resulted in severe anemia.

Conclusion

This case highlighted the need to consider uncommon causes, such as leech infestations, in the differential diagnosis of anemia and oropharyngeal bleeding, particularly in rural areas with limited access to clean water. Early recognition and intervention are crucial in preventing severe complications. Preventive measures, such as promoting access to safe water and improved sanitation and educating rural communities on the importance of seeking early medical attention for unusual symptoms, are essential for reducing the incidence of leech infestations.

Background

Leeches are blood-sucking endoparasite segmented worms characterized by a small sucker, which contains the mouth, at the anterior end of the body, and a large sucker located at the posterior end [1, 2]. Leeches occur primarily in fresh water and on land. Aquatic leeches may feed on the blood of fish, amphibians, birds, and mammals, or they may eat snails, insect larvae, and worms, while true land leeches feed only on the blood of mammals [1, 3].

They infrequently infest the human body in a condition referred to as hirudinosis [3]. The most common means of leech infestation include drinking unfiltered or contaminated water or coming into contact with them through natural orifices while swimming or bathing in infested water sources. This makes leech infestations more prevalent in developing countries, particularly in rural areas with limited access to safe water supplies [4,5,6]. Once the leeches are ingested, they may adhere to the mucosa of the upper aerodigestive tract and can be found in the nasal cavity, pharynx, larynx, trachea, and esophagus [7,8,9].

Leeches have the ability to consume a blood volume nearly ten times their body weight. They use their anterior sucker to attach to the mucous membrane or skin. They anesthetize the site of attachment with their saliva, which also contains the vasodilator hirudin, making the ingestion of blood more effective [4, 7, 10, 11]. As a result, infestations can go unnoticed until clinical symptoms, such as bleeding or severe anemia, become apparent [4, 10, 11].

A person with a leech infestation may present with epistaxis, hemoptysis, foreign body sensations, voice hoarseness, and respiratory symptoms depending on the site. In severe cases, it can lead to severe anemia, airway obstruction, and even death, particularly in children [3, 6, 12,13,14]. In this case, we present a leech infestation in the oropharyngeal that resulted in anemia in a 65-year-old man.

Case presentation

In this case report, we presented an unusual cause of severe anemia in a 65-year-old male Amhara ethnicity patient resulting from oropharyngeal leech infestation. The patient, a farmer from a rural area in North Wollo, Raya Kobbo, Ethiopia, presented with a 2-week history of spitting blood-tinged saliva. The bleeding was intermittent and some time it became bright red. He also described experiencing a persistent foreign body sensation in his throat, which was accompanied by discomfort and a sensation of fullness in the oropharyngeal area, lightheadedness, and difficulty speaking; 1 week prior to the onset of these symptoms, he had consumed water from a nearby spring, primarily used for livestock. Notably, he had no history of other symptoms associated with upper respiratory or gastrointestinal issues, such as a cough, shortness of breath, vomiting, or bleeding from other sites.

On thorough physical examination, the patient was stable. His vital signs included a pulse rate of 104 beats per minute, a respiratory rate of 32 breaths per minute, blood pressure of 100/70 mmHg, and a temperature of 37.2 °C. The elevated pulse and respiratory rates suggested tachycardia and mild tachypnea, possibly due to discomfort or partial respiratory obstruction caused by the foreign body. Eye examination revealed pale conjunctiva and nonicteric sclera. A detailed oropharyngeal examination uncovered a dark brown cylindrical worm attached to the posterior wall of the oropharynx, with clotted blood surrounding the site of attachment.

The patient was thoroughly informed about the entire procedure to ensure his comfort and cooperation. He was positioned in the supine sniffing position (with neck hyperextension). The tongue was retracted outward using sponge forceps, allowing us to grasp and remove the foreign body, which was identified as a 9.6-cm live leech (Fig. 1). After removal, the site of attachment was compressed with gauze to control bleeding, and any hematoma was removed. The patient was counseled and sent home with home-based iron supplements for 1 month. The counseling emphasized on using clean water and not drinking river water. In addition, he was informed on seeking healthcare early when experiencing health ill health.

Fig. 1

Diagram showing live leech removed from a 65-year-old man at Kobo Health Center, North Wollo, Ethiopia, June 2024

The patient gave written informed consent for the case information and any related photos to be published.

Discussion

In contrast to previously documented cases in Ethiopia and other countries, our case presented two unique aspects. First, the patient was identified during home-based care provided by a mobile medical team, which had been deployed by a global humanitarian organization to provide medical care to conflict-affected population in northern Ethiopia. This contrasts with most documented cases of leech infestations, which are typically identified in clinical settings, where patients seek care for symptoms. The second significant difference relates to the management of the condition. Advanced medical facilities and senior-level ear, nose, and throat (ENT) experts are needed for leach infestation management. In this case, however, the procedure was performed by a junior general practitioner who was part of the mobile medical team. Since the patient refused to be transferred to a higher-level health facility with more advanced resources, the mobile team, with the general practitioner taking the lead, decided to proceed with the extraction at the nearest available health center.

The clinical presentation of leech infestations may vary depending on the site of infestation, but typically includes signs of bleeding such as epistaxis, hemoptysis, hematemesis, and in severe cases, melena, vaginal bleeding, and anemia [1]. A review of relevant literature uncovered two documented cases in Ethiopia. The first case involved a 10-month-old infant who exhibited nasal bleeding and blood-tinged vomiting, and the second case concerned a 6-year-old boy who presented with hematemesis, frequent spitting of blood-stained saliva, fatigue, and anorexia [15, 16]. In addition, three cases of vaginal bleeding due to leech infestation were presented from Eritrea [17]. Similar cases have been reported globally, such as a 15-year-old girl in Tanzania with chest pain, hemoptysis, and severe anemia [13] and a 12-year-old boy in Egypt who had a dry cough and spitting of blood due to leech infestation [18]. Noteworthy cases have also been reported in various regions of the world, such as Iran [19], Pakistan [20], China [21, 22], and Turkey [23].

Management of leech infestations requires a combination of preventive and clinical approaches. Preventive measures focus on ensuring access to clean water and promoting proper sanitation practices [4]. From a clinical perspective, timely diagnosis and intervention are essential to avoid complications. Leech removal can be done with or without anesthesia, depending on the site of infestation and the age of the patient [4, 6, 14]. Generally, leeches in the larynx and trachea need general anesthesia, whereas those in the nose and oropharynx may require no anesthesia [16, 21, 24,25,26], as in our case. Several techniques have been employed effectively for leech removal. Direct laryngoscopy is the gold standard for emergency diagnosis and removal. In our case, we used sponge forceps for removal. This procedure can be performed with or without anesthesia; however, in our case, we opted to use analgesics instead [27]. The successful removal of the leech resulted in the complete resolution of symptoms within 2 weeks, with no post-procedural complications reported.

Some researchers report complications of anemia following leech bites severe enough to require iron supplementation and blood transfusion. Reports from Jordan indicated occurrences of iron-deficiency anemia [24]. In Kenya, a child succumbed to complications related to anemia [8]. Getahun et al. reported a case of severe anemia with a hemoglobin level of 3 mg/dl [16]. In our case, the patient presented with severe anemia, for which iron supplements were provided. However, due to the lack of laboratory services, we were unable to confirm the severity of the anemia with precise hemoglobin measurements.

Conclusion

This case underscores the importance of considering uncommon etiologies in the differential diagnosis of symptoms, particularly those related to the oropharyngeal and respiratory tracts. Individuals from rural areas exposed to unsafe water require special attention, as environmental factors can lead to atypical presentations. Although oropharyngeal leech infestation is rare, healthcare providers should maintain a broad clinical perspective to ensure comprehensive evaluation and appropriate management of patients with unusual symptoms or conditions. Emphasizing the use of clean water sources and avoiding contaminated water bodies, such as rivers, during counseling sessions is crucial to prevent similar incidents in the future. Additionally, educating patients on the importance of seeking early healthcare intervention for any unusual symptoms or health concerns is vital for the timely diagnosis and management of medical conditions.