January 2007 Vol 7 correct A.indd ABSTRACT A 75 years old lady from the Dhaherah Province, Oman, presented at Ibri Hospital, complaining from abnormal vaginal bleeding. Histopathological investigations of a cervical biopsy revealed no atypical features. A worm-like organism was removed from the vagina. Histocytological investigations of the organism revealed typical structures of a leech. The case was identified as vaginal hirudiniasis, probably due to Limnatis nilotica that necessitated a note on internal hirudiniasis. Keywords: internal hirudiniasis, vagina, Limnatis nilotica, Case report, Oman. Vaginal hirudiniasis from Dhaherah Province, Oman: With a Note on Internal Hirudiniasis Mohamed A Idris SULTAN QABOOS UNIVERSITY MEDICAL JOURNAL DECEMBER 2006 VOL 6, NO. 2 SULTAN QABOOS UNIVERSITY© LEECHES OF THE CLASS HIRUDINEA MAY BE aquatic, terrestrial, or amphibious in their hab-itat. They are characteristically bloodsuckers and, like ticks, are adapted to engorge large amounts of blood. They have a twofold medicinal importance: a) as an aid used for bloodletting and b) as injurious to man, painlessly inserting their jaws in the skin or mu- cus membrane of man and produce trickling blood. The medicinal leech (Hirudo medicinalis) has been linked to the practice of medicine for years untold. Its use for blood letting peaked in the mid 1800s. Recently it was used by microvascular and plastic surgeons and by the public, who used it for the treatment of black eyes and varicose veins.1 Internal hirudiniasis is due to aquatic leeches taken into the mouth or gaining entrance to the genitourinary tract (vulva, vagina and urethra), nostrils or conjunctiva from water.2 The presence of leeches in the throat and upper air passages is by far most com- mon than vaginal hirudiniasis. Medically important leeches mostly belong to the genus Limnatis and were reported from various countries in Africa, Asia, South- ern Europe and America.3,4 Human infection with the most notorious species Limnatis nilotica5,6 which lives in small streams, springs, wells, water-troughs, ponds, ditches and reservoirs7 has been recorded in most of the Middle Eastern countries,4 Oman7 and Yemen.8 T H E C A S E A slide containing two sections of a worm was received at the Clinical Microbiology Laboratory, Sultan Qaboos University Hospital, for identification from the Depart- ment of Histopathology and Cytopathology, Royal Hos- pital, Muscat, Sultanate of Oman, with the comment “worm from vagina, have you seen something like this before? The worm was removed from the vagina of a 75 years old lady”. The specimen was originally sent from Ibri Hospital, Dhaherah Province, Sultanate of Oman. The Royal Hospital, also received a white membranous fragment, 1 cm, of cervical biopsy. Naked eye examination, considering the size, gave Department of Microbiology and Immunology, College of Medicine &Health Sciences, Sultan Qaboos University, P.O. Box, 35, Al Khod 123, Muscat, Sultanate of Oman Email: midris@squ.edu.om C A S E S T U D Y العلق الداخلي نبذه عن عمان: مع الظاهرة، من مهبلي علق عنق من (عينة) خزعة أخذ مت مهبلي. نزيف من تشكو وكانت الظاهرة من والسبعني اخلامسة سن سيده في عبري ملستشفى وصلت امللخص: يعزى قد مهبلي علق حالة تشخيص للكائن اتبرية الدراسة أكدت السيدة. مهبل من الدودة يشبه كائن أخرج طبيعيا. النسيج وكان الرحم العلق الداخلي. عن نبذه إضافة أستدعى مما النيلية بالبحيراء لإلصابة عمان. ، النيلية البحيراء ، حالة تقرير ، املهبل ، الداخلي املفردات املفتاحية: داء العلق 84 M O H A M M E D A I D R I S the impression that the sections might be of Taenia segment/s that had incidentally entered the vagina. However, microscopic examination of the well-pre- pared sections and consultation of Pearse et al.9 re- vealed typical sections of a leech. The case was identi- fied as vaginal hirudiniasis, probably due to Limnatis nilotica. D I S C U S S I O N Small, young leeches can quickly enter the mouth or nostrils and attach to the wall of the respiratory pas- sages, usually far back in the pharynx or larynx caus- ing epistaxis and haemoptysis. They grow rapidly and reach a large size and often do much damage. Nor- mally the puncture is not painful, but the wounds re- main open for a long time and heal slowly, even when not infected with pyogenic organisms. Moreover, un- controlled bleeding from the multiple abandoned sites has reportedly produced sufficient blood loss to cause anaemia and death.2 When a leech bites it excretes a local anaesthetic that allows it to bite and suck blood without caus- ing pain to the host.10 It also secretes an anticoagu- lant (hirudin) from its salivary glands that inhibits Table 1: Summary of manifestations and management of internal hirudiniasis reported from the region Country Number and age of affected individuals Site of infestation Clinical presentation Methods of removal Treatment Iraq3 9 (3-60) years Nose, larynx, behind uvula Bleeding, epistaxis, cough Detachment by forceps Iraq4 60 years male Under vocal cord Cough, hoarseness and hemoptysis Lignocaine - Ethiopia13 50 years female Posterior vaginal fornix Bleeding and anaemia 1% Lidocaine Blood transfusion Ethiopia14 Larynx Obstruction? Local anaesthetic - Ethiopia15 Vaginal wall Bleeding Detachment by forceps - India16 16 years female Uterine cavity Bleeding Dilatation & curettage - India17 14 + (3-36) years Nose and nasopharynx Nasal blockage, bleeding, earache, epistaxis, headache, crawling sensation or pain Weak solution of chloroform and turpentine oil Zylocain drops, nasal packing in some cases India18 5 (3-12) years Nostrils Epistaxis, blockage of nostrils Hypertonic saline Symptomatic nasal packing India19 - Male urethra Bleeding - - India20 - Male urethra Bleeding - - Turkey21 Child Eye Ocular trauma, iris prolapse, subconjuntival haemorrhage Extraction Topical antibiotic and cycloplegic agent Oman (personal Communication) 18 years boy from Dhofar Nose Nasal blockage Fire 85 VA G I N A L H I R U D I N I A S I S F R O M D H A H E R A H P R O V I N C E , O M A N : WI T H A N O T E O N I N T E R N A L H I R U D I N I A S I S thrombin in the clotting process11,12 and histamine- like substances to prevent closure of capillaries6,12, thus causing continuous bleeding even after the leech has dropped or been removed. In addition to the clini- cal symptoms presented in the table,3,4,13-21other leech bite complications include bullae, haemorrhage, pru- ritus, wheal formation, necrosis and ulceration.22 The Table3,4,13-21 show that various methods were used to remove the leech, However, it is worthwhile mention- ing that removal may be hastened by applying a few drops of brine, alcohol or vinegar to the site or a flame skillfully applied to the worm. The leech should not be pulled off forcibly, as the trauma resulting from the bite and from the leech jaws remaining in the lesion can predispose the lesion to malignancy.23 Internal hirudinaisis is not uncommon in the Mid- dle East, India, and Ethiopia3,4,13-20 and abnormal vagi- nal bleeding is common in internal hirudinasis.13,15,16,24 However, the presentation of this old lady with abnor- mal vaginal bleeding was suggestive of cervicitis/car- cinoma and the histopathological examination of the cervical biopsy report reads “initial and deeper sec- tions show strips of superficial, keratotic squamous epithelium. No submucosa included, no atypical fea- tures noted”. Although abnormal vaginal bleeding is one of the commonest complications among women, vaginal hirudiniasis has to be included in the differ- ential diagnosis of abnormal vaginal bleeding, par- ticularly in post-menopausal cases13 and girls.15 Also, attention should be given to leech infestation in the dif- ferential diagnosis of ocular trauma with iris prolapse in patients with a history of swimming in streams and lakes21 and so create awareness among professionals working in areas where aquatic leech infestation is prevalent.10,25 A C K N OW L E D GE ME N TS I would like to thank Dr. M M Musa, Previous Head Department of Histopathology and Cytopathology, Royal Hospital, Ministry of Health, Sultanate of Oman for sending the slide for identification. I am also grate- ful to Dr. K Al-Haj, Royal Hospital and to Dr. A Al- Hakeem, Ibri Hospital for their help in retrieving the reports of this case. R E F E R E N C E S 1. Adams LA. The emergency management of a medicinal leech bite. Ann Emerg Med 1989; 18:316–319. 2. Cook GC. Manson’s Tropical Diseases 20st ed, London: Saunders, 1996. 3. Almallah Z. Rare and interesting cases: Internal hirudiniasis as an unusual cause of haemoptysis. Brit J Dis Chest 1968; 62:215-218. 4. Almallah Z. Internal hirudiniasis in man with Limnatis nildica, in Iraq. J Parasitol 1968; 54:637-638. 5. Hoeppil R, Tang CC. Leeches in old Chinese and Eu- ropean medical literature. Chinese med J 1941; 59:359- 378. 6. Payton B. History of medicinal leech applying and med- ical references. In: Muller KJ, Nicholls JG, Stent GS, eds. Neurobiology of the leech. New York: Cold Spring Har- bor Publications, 1981. 7. Nesemann H, Forster R. First record of Limnatis niloti- ca from Oman (Hirudinea : Hirudinidae). Miscnea Zool Hung 1997; 11:11-14. 8. Al Safadi MM, El-Shimy NA. Freshwater leeches from Yemen. Hydrobiol 1993; 263:185-190. 9. Pearse V, Pearse J, Buchsbaum M, Buchsbaum R. Living Invertebrates. 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