Leeches

February 2008

Hirudo medicinalis L. Phylum: Annelida

Fresh water leech , medicinal leech

Uses

Leeches have been used for bloodletting, wound healing, and stimulating blood flow at postsurgical sites. Use in osteoarthritis is being investigated, but there is a lack of clinical information to make recommendations.

Dosing

Consult existing guidelines for the use of leeches.

Contraindications

Arterial insufficiency, previous exposure to leeches (risk of allergic reaction), immunosuppression (risk of infection), patient refusal to accept possible subsequent blood transfusions, and unstable medical conditions have been described as contraindications for extensive leech therapy.

Pregnancy/Lactation

Information regarding safety in pregnancy and lactation is lacking. Avoid use because of risk of infection and anemia.

Interactions

None well documented.

Adverse Reactions

Extensive blood loss. Allergic reactions and infections may develop.

Toxicology

No data.

There are more than 700 species of leeches, all of which are carnivorous. ¹ The leech is an hermaphrodite, containing both male and female sexual organs, but is not self-fertile.

The use of medicinal leeches ( H. medicinalis ) is preferred because of their ability to bite deeply and cause prolonged bleeding even after they are detached. H. medicinalis can reach up to 12 cm long, but is generally smaller, weighing 1 to 1.5 g before feeding. H. medicinalis has both anterior and posterior suckers, with the head located at the narrow tapered end. The anterior sucker has 3 jaws, each with 60 to 100 teeth for biting. The posterior sucker is used for attachment and crawling. ¹

Leeches obtained from commercial breeders are easily maintained in a chlorine-free salt solution at 10° to 20°C. Under such conditions, leeches can survive for up to 18 months.

The medicinal use of leeches dates back to ancient Egyptians around 1300 BC; the Greek physician Galen (130 to 201 AD) commonly used leeches for bloodletting. The 19th century heralded the widespread use of leeches for bloodletting—leading to a leech shortage from 1825 to 1850 in France requiring the importation of leeches from America. ^1, , ^2, , ^3, , ^4, , ^5, , ^6, By the end of the 19th century, the medicinal use of leeches had lost popularity due to adoption of the modern concepts of pathology and microbiology. ¹

Different species of leeches secrete varying compounds with differing hematological actions. ^7, , ⁸

Following attachment, H. medicinalis secretes hirudin, a selective thrombin inhibitor, which enhances bleeding and prevents coagulation. ^1, , ^9, , ^10, Hirudin was first described more than a century ago and characterized as a 65-amino acid peptide with antithrombokinase activity. ^1, Early therapeutic studies of hirudin were limited by low natural yield, but the compound has recently been produced in larger quantities by recombinant gene techniques. ^11, , ^12, Recombinant hirudin binds avidly to thrombin, thus low doses inhibit venous thrombosis in animals. Extracts from leeches have been marketed in creams for topical application. In addition to hirudin, leeches secrete hirustasin, which selectively inhibits tissue kallikreins; antistasin and ghilanten, which inhibit Factor Xa; calin, apyrase, and saratin, which inhibit platelet aggregation; a histamine-like compound, which causes vasodilation; hyaluronidase and collagenase, which increase permeability; and bdellin and eglin, which are proteinase inhibitors. ^1, , ^10, , ^13, , ¹⁴

There is conflicting evidence as to whether an anesthetic is secreted in H. medicinalis . ^4, , ^15, , ¹⁶ Theromyzon is widely distributed in the tissue of the leech Theromyzon tessulatum and has angiotensin-converting, enzyme-like properties, ^8, and peptides with antimicrobial properties have been identified. ¹⁷

Ischemic tissue Medicinal leeches are used to stimulate the flow of blood at postoperative surgical sites to increase the success of tissue transplants, and are also used in reduction mammoplasty and for surgical reattachment of amputated extremities. ^2, , ^15, , ¹⁶

After attaching to the site, leeches secrete compounds that reduce blood viscosity. They provide the drainage needed to permit decongestion and to preserve tissue viability until normal venous flow is established. ¹⁸

The salvage of ischemic tissue has been investigated in a randomized clinical trial of rodent epigastric skin flaps, demonstrating an increase in flap survival rates. ^1, A porcine model of venous-compromised flaps showed increased blood flow as measured with laser Doppler perfusion studies. In human ear replantations, fluorescein measurements demonstrated decreased venous congestion with the use of leeches. ^1, , ¹⁹

Other case reports support the use of leeches in purpura fulminans consequent to meningococcal septicemia, ^10, penile replantation, ^20, finger crush, ring-avulsion injuries, ^21, , ^22, and head and neck free-tissue transfer. ⁹

Other uses Recombinant hirudin has been used successfully in the treatment of Kasabach-Merritt syndrome, a condition leading to loss of circulating platelets and fibrinogen. Paradoxically, low-dose subcutaneous hirudin normalized fibrinogen and platelet activity. ¹¹

In a randomized trial, the use of leeches significantly reduced knee pain in adults with knee osteoarthritis compared with topical diclofenac. ²³

Institutional guidelines may exist for the use of leeches. Leeches are applied from 2 to 4 times a day for up to a week. Feeding is complete in about 20 minutes, at which time the leech drops off. Removal of the leech may be hastened by applying solutions of salt, vinegar, a flame, or a local anesthetic. Leeches should not be forcibly removed. Bleeding from the attachment site usually continues for several hours. Reuse of leeches is discouraged to minimize the development of cross-infection. ^1, , ^18, , ^24, , ²⁵

Information regarding safety in pregnancy and lactation is lacking. Avoid use due to risk of infection and anemia.

None well documented. Closely monitor conditions requiring concomitant anticoagulant therapy.

One study found no changes in ipsilateral activated partial thromboplastin or prothrombin times when leeches were applied to an intact hand. This suggests that systemic or local anticoagulation is not likely to occur and that the risk of interference with other therapies may be small. ²⁶

Blood loss Leeches may consume up to 50 mL blood per application, and their secretions during a single feed can prevent coagulation (in vitro) of up to 100 mL human blood. Passive bleeding after detachment can continue up to 72 hours but most commonly continues for about 5 hours. Blood loss may occur, sometimes requiring transfusions. ^9, , ^25, , ²⁷

Infection H. medicinalis should be considered a possible vector of infectious diseases. The gram-negative Aeromonas hydrophilia is the predominant microbial species found in leeches. ^1, , ^9, , ^28, , ²⁹ Serratia , Klebsiella , and Pseudomonas have also been isolated, ^10, , ^30, , ^31, , ^32, , ^33, and patients should receive appropriate prophylactic antibiotic therapy. Older studies suggested possible transmission of HIV and hepatitis, but this is less likely with the use of farmed leeches. ^34, Reuse of leeches is not recommended due to concerns of disease transmission. ⁴

Other Local allergic reactions and anaphylaxis have been reported. ^35, Leeches found in the nose, throat, and the GI tract have caused complications. ^36, , ^37, , ^38, , ³⁹

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2. Hayden RE , Phillips JG , McLear PW . Leeches. Objective monitoring of altered perfusion in congested flaps. Arch Otolaryngol Head Neck Surg . 1988;114(12):1395-1399. PubMed

3. Rao J , Whitaker IS . Use of Hirudo medicinalis by maxillofacial surgical units in the United Kingdom: current views and practice. Br J Oral Maxillofac Surg . 2003;41(1):54-55.

4. Whitaker IS , Izadi D , Oliver DW , Monteath G , Butler PE . Hirudo medicinalis and the plastic surgeon. Br J Plast Surg . 2004;57(4):348-353. PubMed

5. Ventura HO , Mehra MR . Bloodletting as a cure for dropsy: heart failure down the ages. J Card Fail . 2005;11(4):247-252. PubMed

6. Hodgson D . Of gods and leeches: treatment of priapism in the nineteenth century. J R Soc Med . 2003;96(11):562-565. PubMed

7. Ledizet M , Harrison LM , Koskia RA , Cappello M . Discovery and pre-clinical development of antithrombotics from hematophagous invertebrates. Curr Med Chem Cardiovasc Hematol Agents . 2005;3(1):1-10.

8. Rivière G , Michaud A , Deloffre L , et al. Characterization of the first non-insect invertebrate functional angiotensin-converting enzyme (ACE): leech TtACE resembles the N-domain of mammalian ACE. Biochem J . 2004;382(pt 2):565-573. PubMed

9. Chepeha DB , Nussenbaum B , Bradford CR , Teknos TN . Leech therapy for patients with surgically unsalvageable venous obstruction after revascularized free tissue transfer. Arch Otolaryngol Head Neck Surg . 2002;128(8):960-965. PubMed

10. Dippenaar R , Smith J , Goussard P , Walters E . Meningococcal purpura fulminans treated with medicinal leeches. Pediatr Crit Care Med . 2006;7(5):476-478. PubMed

11. Wallis RB . Hirudins and the role of thrombin: lessons from leeches. Trends in Pharmacol Sci . 1988;9(12):425-427. PubMed

12. Hand R , et al. A review of the pharmacology, clinical applications, and toxicology of hirudin and hirulog. Transgenica: J Clin Biotechnol . 1994;1:1. PubMed

13. Deckmyn H , Stassen JM , Vreys I , Van Houtte E , Sawyer RT , Vermylen J . Calin from Hirudo medicinalis , an inhibitor of platelet adhesion to collagen, prevents platelet-rich thrombosis in hamsters. Blood . 1995;85(3):712-719. PubMed

14. Harsfalvi J , Stassen JM , Hoylaerts MF , et al. Calin from Hirudo medicinalis , an inhibitor of von Willebrand factor binding to collagen under static and flow conditions. Blood . 1995;85(3):705-711. PubMed

15. Baskova IP , Khalil S , Nartikova VF , Paskhina TS . Inhibition of plasma kallikrein, kininase and kinin-like activities of preparations from the medicinal leech. Thrombosis Research . 1992;67(6):721-730. PubMed

16. Rados C . Beyond bloodletting: FDA gives leeches a medical makeover. FDA Consum . 2004;38(5):9. PubMed

17. Salzet M . Neuropeptide-derived antimicrobial peptides from invertebrates for biomedical applications. Curr Med Chem . 2005;12(26):3055-3061. PubMed

18. Abrutyn E . Hospital-associated infection from leeches. Ann Intern Med . 1988;109(5):356-358. PubMed

19. Frodel JL Jr , Barth P , Wagner J . Salvage of partial facial soft tissue avulsions with medicinal leeches. Otolaryngol Head Neck Surg . 2004;131(6):934-939. PubMed

20. Mineo M , Jolley T , Rodriguez G . Leech therapy in penile replantation: a case of recurrent penile self-amputation. Urology . 2004;63(5):981-983. PubMed

21. Durrant C , Townley WA , Ramkumar S , Khoo CT . Forgotten digital tourniquet: salvage of an ischaemic finger by application of medicinal leeches. Ann R Coll Surg Engl . 2006;88(5):462-464. PubMed

22. Tuncali D , Terzioglu A , Cigsar B , Aslan G . The value of medical leeches in the treatment of class IIC ring avulsion injuries: report of 2 cases. J Hand Surg [Am] . 2004;29(5):943-946. PubMed

23. Michalsen A , Klotz S , Lüdtke R , Moebus S , Spahn G , Dobos GJ . Effectiveness of leech therapy in osteoarthritis of the knee: a randomized, controlled trial. Ann Intern Med . 2003;139(9):724-730. PubMed

24. Adams SL . The emergency management of a medicinal leech bite. Ann Emerg Med . 1989;18(3):316-319. PubMed

25. Rao P , Bailie FB , Bailey BN . Leechmania in microsurgery. Practitioner . 1985;229(1408):901-905. PubMed

26. Blackshear JL , Ebener MK . Leeching, hirudin, and coagulation tests. Ann Intern Med . 1994;121(2):151-152. PubMed

27. Ikizceli I , Avsarogullari L , Sözüer E , Yürümez Y , Akdur O . Bleeding due to a medicinal leech bite. Emerg Med J . 2005;22(6):458-460. PubMed

28. Ardehali B , Hand K , Nduka C , Holmes A , Wood S . Delayed leech-borne infection with Aeromonas hydrophilia in escharotic flap wound. J Plast Reconstr Aesthet Surg . 2006;59(1):94-95. PubMed

29. Steer A , Daley AJ , Curtis N . Suppurative sequelae of symbiosis. Lancet . 2005;365(9454):188. PubMed

30. Dickson WA , Boothman P , Hare K . An unusual source of hospital wound infection. Brit Med J . 1984;289(6465):1727-1728. PubMed

31. Kourt B , Segars LW , Davis TW . When the prescription says “leeches.” Am J Hosp Pharm . 1994;51(17):2113-2114, 2116. PubMed

32. Bickel KD , Lineaweaver WC , Follansbee S , Feibel R , Jackson R , Buncke HJ . Intestinal flora of the medicinal leech Hirudinaria manillensis . J Reconstr Microsurg . 1994;10(2):83-85. PubMed

33. Wilken GB , Appleton CC . Bacteriological investigation of the occurrence and antibiotic sensitivities of the gut-flora of the potential southern African medicinal leech, Asiaticobdella buntonensis (Hirudinidae). J Hosp Infect . 1993;23(3):223-228. PubMed

34. Nehili M , Ilk C , Mehlhorn H , Ruhnau K , Dick W , Njayou M . Experiments on the possible role of leeches as vectors of animal and human pathogens: a light and electron microscopy study. Parasitol Res . 1994;80(4):277-290. PubMed

35. Tseng CC , Ho CY . Removal of a nasal leech: a safe and effective method. Otolaryngol Head Neck Surg . 2005;132(5):814-815. PubMed

36. Bergua A , Vizmanos F , Monzón FJ , Blasco RM . Unavoidable epistaxis in the nasal infection of leeches [in Spanish]. Acta Otorrinolaringol Esp . 1993;44(5):391-393. PubMed

37. Uygur K , Yasan H , Yavuz L , Dogru H . Removal of a laryngeal leech: A safe and effective method. Am J Otolaryngol . 2003;24(5):338-340. PubMed

38. Kuehnemund M , Bootz F . Rare living hypopharyngeal foreign body. Head Neck . 2006; 28(11):1046-1048. PubMed

39. Krüger C , Malleyeck I , Olsen OH . Aquatic leech infestation: a rare cause of severe anaemia in an adolescent Tanzanian girl. Eur J Pediatr . 2004;163(6):297-299. PubMed