Don’t drink the water

Well, not unless you filter it first. This article discusses the diagnosis and treatment of a rare condition, and pitfalls of an inadequate physical examination.

To begin, an 8-year-old girl presented with hemoptysis, but duration was not given. Vitals, labs, and initial physical examination were normal, so they did what we are trained to do in the first year of medical school. Basically, keep asking questions until you can come up with clues to diagnose your zebra. The child at some point endorsed drinking unfiltered water (from a tap!) a few days prior to presentation. Armed with this new knowledge, they went back and examined the patient again to find the culprit, a live leech 5cm long, and 10mm wide on the posterior pharynx. They removed it, and everything was right in the world.

There are some pointers to be had from this article. Namely, to suspect leech endoparasitism of the oro- and nasopharynx in patients presenting with bleeding complaints and recent exposure to leech-prone areas (lakes, streams, Turkish tap water). They reference a hodge-podge of case reports with more serious outcomes to prove their point.

They then give some advice on removal of leeches, such as being wary of breaking it apart and leaving parts behind by using too strong of traction. However, it also recommends irrigation with noxious solutions including vinegar, turpentine, alcohol, dimethyl phthalate, 30% cocaine(!), and others. I can’t recommend doing this even under general anesthetic. I can recommend doing a better exam of the pharynx when evaluating for hemoptysis, as this was a big critter in the back of the throat, and was moving around per their report. Not exactly sure how they missed it on the first look.

An interesting if difficult read secondary to issues with syntax, likely from translation. The fact is, you’ll never diagnose something you don’t consider, and now you have another item on the differential.

Bulent A, Ilknur O, Beray S, Tulin C, Ulku T, Yildiz D. An unusual cause of hemoptysis in a child: live leech in the posterior pharynx. [PMID 20962717]

I have no apologies for those of you who have the Dave Matthews Band song stuck in your head now

Further Reading

Emergency physician with interests in wilderness and prehospital medicine. Medical Director of the Texas State Aquarium, Padre Island National Seashore, Robstown EMS, and Code 3 ER | EBM gone Wild | @EBMGoneWild |

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