Indications and complications of medicinal leech therapy

Cutaneous lymphoid hyperplasia induced by Hirudo medicinalis (leeches)

For centuries, Hirudo medicinalis (medicinal leech) has been used as a remedy to treat many discomforts, such as muscle and joint pain. Nowadays, using leech in reconstructive surgery, microsurgery, wound and flap healing, venous insufficiency, varicosities and many other disorders has increased. In this study, we report a 45 year old female patient with six pruritic papules on her legs since10 months ago that appeared about 4 weeks after one session of leech application. Skin biopsy was performed on one of the papules, and in histopathology, superficial ulceration with a dense superficial and deep inflammatory infiltrate within the dermis composed of lymphocytes and eosinophils detected that considering history of leech application at this site, these constellation of data was compatible with the diagnosis of cutaneous lymphoid hyperplasia induced by leeches and the patient was cured by a topical steroid and cryotherapy.

Leeching as Salvage Venous Drainage in Ear Reconstruction: Clinical Case and Review of Literature

Background

Ear avulsion is a rare complication of different traumas, such as car accidents, human or animal bites and stab wounds, and can result in dramatic cosmetic consequences for the patient. Ear replantation, revascularization, and reattachment are the options offering best aesthetic results. But venous outflow insufficiency is responsible for a high rate of failures. Leeching is one the most efficient methods to relieve venous congestion. It has been used as an alternative venous outflow in case of severe impairment of the physiologic one.

Methods

We present a case of successful rescue of a congested reattached ear by leeching after subtotal avulsion, along with a review of the literature on cases of avulsed auricle reconstruction salvaged by hirudotherapy. Data were collected and analyzed to identify a best regimen to deal with venous congestion.

Results

More than 130 cases of avulsed auricle savage are described in the literature, in a fourth of which leech therapy was used in the management of venous congestion.

Discussion

In case of both venous outflow deficit or absence, leeches are a potentially successful option to correct the congestion while new veins reestablish normal physiology. The need for anticoagulant/antiaggregant therapy, antibiotics, and often blood transfusion are the main pitfalls of leeching.

Conclusion

Leeches can be considered a salvage method for ear replantation and reattachment in those cases that lack venous outflow in the presence of valid arterial inflow.

Aeromonas sobria serine protease (ASP): a subtilisin family endopeptidase with multiple virulence activities

Aeromonas sobria serine protease (ASP) is secreted from Aeromonas sobria, a pathogen causing gastroenteritis and sepsis. ASP resembles Saccharomyces cerevisiae Kex2, a member of the subtilisin family, and preferentially cleaves peptide bonds at the C-terminal side of paired basic amino acid residues; also accepting unpaired arginine at the P1 site. Unlike Kex2, however, ASP lacks an intramolecular chaperone N-terminal propeptide, instead utilizes the external chaperone ORF2 for proper folding, therefore, ASP and its homologues constitute a new subfamily in the subtilisin family. Through activation of the kallikrein/kinin system, ASP induces vascular leakage, and presumably causes edema and septic shock. ASP accelerates plasma clotting by α-thrombin generation from prothrombin, whereas it impairs plasma clottability by fibrinogen degradation, together bringing about blood coagulation disorder that occurs in disseminated intravascular coagulation, a major complication of sepsis. From complement C5 ASP liberates C5a that induces neutrophil recruitment and superoxide release, and mast cell degranulation, which are associated with pus formation, tissue injury and diarrhea, respectively. Nicked two-chain ASP also secreted from A. sobria is more resistant to inactivation by α2-macroglobulin than single-chain ASP, thereby raising virulence activities. Thus, ASP is a potent virulence factor and may participate in the pathogenesis of A. sobria infection.

Management strategies for Janu Sandhigata Vata vis-a-vis osteoartheritis of knee: A narrative review

INTRODUCTION

Ayurveda has described about the pathogenesis and the treatment of various disorders, the incidence of some of which have increased in the present scenario. Janu Sandhigata Vata correlated with osteoarthritis (OA) of the knee joint is one such chronic, degenerative, inflammatory disease which has a great impact on the quality of the life of an individual. Different modalities of treatment have been explained in the classics to tackle the condition effectively.

METHODOLOGY

In the present study, an attempt has been made to review the various clinical research works done in the management of OA of the knee, which are registered in various research portal. In AYUSH Research Portal using the keywords Ayurveda-clinical research-musculoskeletal disorders-osteoarthrosis of knee-Janu Sandhigata Vata and in PubMed using clinical research - Ayurveda-OA. The studies reviewed were categorized depending on the treatment used in the management of the condition.

RESULTS

Fifty three research works were registered under AYUSH Research Portal with 34 full papers. There were 12 research papers in PubMed, out of which 6 papers which dealt with OA of the knee were reviewed. Among these six, three already existed in AYUSH Research Portal. The results were discussed by categorizing the studies as per the treatment used.

CONCLUSION

Among the papers reviewed, most of them dealt with few modalities of treatment rather than the complete classical line of the treatment. The evidence-based research involving multimodality treatment with long-term follow-up covering various aspects of prevention and cure has to be conducted which is the need of the hour.

Hirudotherapy in Medicine and Dentistry

The concept of Unani medicine is based on balancing body humours, the imbalance of which causes diseases. The application of leech therapy in medical and dental science is well recognized. Although easy and non-invasive, complications also exist. The article aims to presents a brief review on the applications of leech therapy. The physiological effect, along with its therapeutic role in cancer, diabetes and dentistry have been underlined. Complications of leech therapy have also been dealt with.

Ciprofloxacin-resistant Aeromonas infection following leech therapy for digit replantation: report of 2 cases

Medicinal leeches are commonly used after finger replantation to treat surgically unsalvageable venous congestion. Infection from Aeromonas hydrophila is a recognized complication of leech therapy that can be underestimated by the medical community. Ciprofloxacin and trimethoprim-sulfamethoxazole are the most commonly recommended prophylactic antibiotics used to prevent A. hydrophila infections during leech therapy. Here, we report 2 cases of ciprofloxacin-resistant Aeromonas infections, occurring within 4 months of each other. Both cases developed after leech therapy for unsuccessful digital replantation. These infections were successfully treated with ceftriaxone. Ciprofloxacin-resistant Aeromonas should be recognized when determining prophylactic antibiotic protocols for replant centers when leech therapy is used for finger replantation.

Infections following the application of leeches: two case reports and review of the literature

INTRODUCTION

Since the 1980s, leeches have been ingeniously used in the management of venous flap congestion. The presence of anticoagulative substances in their saliva improves the blood drainage. Their digestive tract contains several bacterial species, the main ones being Aeromonas hydrophila and Aeromonas veronii biovar sobria, which contribute to the digestion of ingested blood. These bacteria can be the cause of infections.

CASE PRESENTATION

We report two cases of septicemia related to Aeromonas veronii biovar sobria that presented after leeches had been applied to congested transverse rectus abdominis myocutaneous flaps for delayed mammary reconstructions.Patient number 1 was a 55-year-old Caucasian woman who underwent a delayed breast reconstruction procedure. On the sixth postoperative day she showed a clinical presentation of septicemia. Aeromonas veronii biovar sobria was identified in the patient's skin and blood bacteriological samples. Her fever ceased after 4 days of antibiotic treatment.Patient number 2 was a 56-year-old Caucasian woman who underwent a delayed breast reconstruction procedure. On the seventh postoperative day we noticed that she showed a clinical presentation of septicemia. Aeromonas veronii biovar sobria was identified in the patient's blood cultures and local bacteriological samples. An antibiogram showed resistance to amoxicillin/clavulanic acid. Her fever ceased on the eleventh postoperative day after 4 days of antibiotic treatment.

CONCLUSION

The rate of infection after application of leeches is not negligible. The concentration of Aeromonas inside the digestive tracts of leeches largely decreases when the patient is under antibiotic therapy. These germs are sensitive to third-generation cephalosporins and fluoroquinolones and resistant to amoxicillin/clavulanic acid. We recommend preventive treatment based on classical measures of asepsis and on oral antibioprophylaxy with a fluoroquinolone during the whole period of treatment by leeches.

The efficacy of medicinal leeches in plastic and reconstructive surgery: a systematic review of 277 reported clinical cases

BACKGROUND

Although there are numerous case reports and small case series describing the experiences of leech therapy in various circumstances, there are relatively few large studies evaluating the effectiveness of leeching to relieve venous congestion. The therapeutic value of leeching is illustrated by these reports but the current literature lacks a cohesive summary of previous experiences.

METHODS

An electronic search of PubMed, the Cochrane library and the Centre for Reviews and Dissemination between 1966 and 2009 was used to retrieve human studies published in the English language evaluating outcomes following leech therapy. The "success" and "failure" of leech therapy were the primary outcome measures and secondary outcomes included complications, number of leeches used, pharmacological adjuncts and blood transfusion requirements.

RESULTS

In total, out of 461 articles, 394 articles met the exclusion criteria. The 67 included papers reported on 277 cases of leech use with an age range of 2-81 years and a male to female ratio of almost 2:1. The overall reported "success" rate following leech therapy was 77.98% (216/277). In terms of secondary outcome measures, 49.75% of cases (N = 101) required blood transfusions, 79.05% received antibiotics (N = 166) and 54.29% received concomitant anticoagulant therapy. The overall complication rate was 21.8%.

CONCLUSION

In the absence of robust randomized controlled trials on which the evidence may be based, this synthesis of current best evidence guides clinicians during the process of consenting patients and using leeches in their practice.

Allium sativum L.: the anti-immature leech (Limnatis nilotica) activity compared to Niclosomide

This study was carried out to determine the effects of methanolic extracts of Allium sativum L. on Limnatis nilotica compared with Niclosomide. In this experimental study in September 2010, a number of leeches (70 in total) from the southern area of Ilam province were prepared, and the effects of methanolic extract of A. sativum L. with Niclosomide as the control drug were compared and distilled water was evaluated as the placebo group which investigated L. nilotica using anti-leech assay. The average time of paralysis and death of L. nilotica for Niclosomide (1,250 mg/kg) and the methanol extract of A. sativum L. (600 μg/ml) were 6.22 ± 2.94 and 68.44 ± 28.39 min, respectively. Distilled water and garlic tablets at a dose of 400 mg were determined as the inert group. In this research, the attraction time of the leeches' death among different treatments is significant. In this study, it was determined that Niclosomide, with an intensity of 4+, and methanolic extracts of A. sativum L., with an intensity of 3+, have a good anti-leech effect and can be shown to be effective in cases of leech biting, while distilled water was negative.

Medicinal leeches and the microsurgeon: a four-year study, clinical series and risk benefit review

BACKGROUND

There are case reports and small series in the literature relating to the use of medicinal leeches by plastic surgeons; however, larger series from individual units are rare. The aim of this article is to present a comprehensive 4-year case series of the use of medicinal leeches, discuss the current evidence regarding indications, risks, and benefits and highlight the recent updates regarding leech speciation.

METHODS

Patients prescribed leeches in a 4-year period (July 2004-2008) were collated from hospital pharmacy records (N = 35). The number of leeches used, demographic, clinical, and microbiological details were retrospectively analyzed.

RESULTS

Thirty-five patients were treated with leeches. The age range was 2 to 98 years (mean = 49.3). Leeches were most commonly used for venous congestion in pedicled flaps and replantations. Blood transfusions were necessary in 12 cases (34%) [mean = 2.8 units, range 2-5 units]. Our infection rate was 20% (7/35) including five infections with Aeromonas spp. (14.2%). The proportion of patients becoming infected after leech therapy was significantly greater in the group of patients that did not receive prophylactic antibiotic treatment (Fisher's Exact test P = 0.0005). In total, 14 cases (40%) were salvaged in entirety, in 7 cases 80% or more, in 2 cases 50 to 79%, and in 1 case less than 50% of the tissues were salvaged. In 11 cases (31%), the tissues were totally lost.

CONCLUSION

Our study highlights both the benefits and the risks to patients in selected clinical situations and also the potential risks. The routine use of antibiotic prophylaxis is supported. In view of the emerging evidence that Hirudo verbana are now used as standard leech therapy, and the primary pathogen is Aeromonas veronii, until a large prospective multicenter study is published, large series of patients treated with leeches should be reported.

Medicinal leeches for the treatment of venous congestion and hematoma after plastic reconstructive surgery

BACKGROUND

Leeches were used for medical purposes as long as 2 000 years ago in ancient Egypt. In recent years the use of medicinal leeches became rather popular again, e. g. to improve blood circulation in ischemic tissue after reconstructive plastic surgery.

PATIENTS AND METHODS

In a single center, retrospective study 23 consecutive cases were analyzed in which medicinal leeches had been used therapeutically after plastic reconstructive surgery. All cases were categorized regarding the indication for leech therapy, the onset, the duration, the number of leeches and the number of sessions.

RESULTS

Among the group of patients there were 7 female and 16 male patients with a mean age of 73 ± 14 years (48-94 years) altogether. The main indications were venous congestion (12/23; 52 %) and hematoma (9/23; 39 %). Two cases were diagnosed with a necrosis of the tip of the flap and therefore received leech therapy (2/23; 9 %). The average number of leeches was 2.6 leeches/session, the number of sessions was 1.7 ± 0.8. 20/23 patients (87 %) showed a restitutio ad integrum after leech therapy, in 3/23 patients (13 %) a necrosis of the tip of the flap could not be prevented. A clinical improvement was noticed after an average of 1.1 ± 0.3 days.

CONCLUSIONS

The early application of medicinal leeches can improve local hemodynamic conditions. Leech therapy is a simple and effective method; the cost efficiency of the treatment is high.

The genus Aeromonas: taxonomy, pathogenicity, and infection

Over the past decade, the genus Aeromonas has undergone a number of significant changes of practical importance to clinical microbiologists and scientists alike. In parallel with the molecular revolution in microbiology, several new species have been identified on a phylogenetic basis, and the genome of the type species, A. hydrophila ATCC 7966, has been sequenced. In addition to established disease associations, Aeromonas has been shown to be a significant cause of infections associated with natural disasters (hurricanes, tsunamis, and earthquakes) and has been linked to emerging or new illnesses, including near-drowning events, prostatitis, and hemolytic-uremic syndrome. Despite these achievements, issues still remain regarding the role that Aeromonas plays in bacterial gastroenteritis, the extent to which species identification should be attempted in the clinical laboratory, and laboratory reporting of test results from contaminated body sites containing aeromonads. This article provides an extensive review of these topics, in addition to others, such as taxonomic issues, microbial pathogenicity, and antimicrobial resistance markers.

Characterization of the digestive-tract microbiota of Hirudo orientalis, a european medicinal leech

FDA-approved, postoperative use of leeches can lead to bacterial infections. In this study, we used culture-dependent and culture-independent approaches to characterize the digestive-tract microbiota of Hirudo orientalis. Surprisingly, two Aeromonas species, A. veronii and A. jandaei, were cultured. Uncultured Rikenella-like bacteria were most similar to isolates from Hirudo verbana.

A possible new cause of spa bath folliculitis: Aeromonas hydrophila

A 34-year-old man presented with a pubic eruption of 4 weeks duration, affecting both himself and his partner. He had been treated unsuccessfully with intravenous and oral dicloxacillin. The eruption was a severely inflammatory folliculitis, with haemo-serous exudate and marked oedema. A clinical diagnosis of herpes simplex virus folliculitis was disproved when routine bacteriology isolated Aeromonas hydrophila and multiple viral polymerase chain reaction studies were negative. Histology demonstrated a chronic folliculitis with no organisms present. Both he and his partner were treated with oral ciprofloxacin 500 mg bd for 6 weeks with clinical clearance of infection, but both developed a scarring alopecia. Infection was attributed to possible contamination of a poorly maintained home spa bath with A. hydrophila.

Immediate use of medicinal leeches to salvage venous congested reverse pedicled neurocutaneous flaps

Reverse pedicled neurocutaneous flaps have recently become popular for reconstructing soft tissue defects of the lower extremity. Venous congestion is a relatively common problem in these flaps in diabetic patients and those with electric burns, and this may cause partial or complete loss if capillary perfusion is not re-established urgently. We describe our experience of 13 neurocutaneous flaps, of which five developed venous congestion and were treated successfully with leeches placed immediately.

Bacterial flora of Hirudo medicinalis and their antibiotic sensitivities in the Middle Black Sea Region, Turkey

The rate of infectious complications of leech therapy is almost 20% because Hirudo medicinalis has endosymbiotic bacteria. The aim of this study was to determine the bacterial flora of H. medicinalis and their antibiotic sensitivities in a region in Turkey. Sixteen adult leeches were collected in Middle Black Sea region, Turkey. They were rubbed onto blood agar plates directly under ether anesthesia to obtain surface cultures. They were then killed to obtain mouth and gut cultures. Culture swabs were applied to blood agar, eosin methylene blue agar, and ampicillin blood agar plates. Gut contents were applied to blood culture medium as well. Bacteria were isolated in 15 of 16 leech surfaces, in 7 of 16 mouths, and in 15 of 16 guts. Isolated bacteria were identified with Analytical Profile Index 32 E and Analytical Profile Index 20 NE (fermentative and nonfermentative respectively). Most common types of cultured bacteria were Aeromonas hydrophila (N = 25), Ochrobacter anthropi (N = 23), nonfermenting Gram-negative rods (N = 12), Acinetobacter lwoffi (N = 3), and A. sobria (N = 2) in 73 isolates. A standard disk diffusion test was performed on isolated bacteria. All isolates were 100% susceptible to ciprofloxacin, cefotaxime, ceftazidime, gentamicin, and trimethoprim/sulfamethoxazole. Because leeches are carriers of Aeromonas and other bacteria, appropriate antibiotic prophylaxis should be administrated to the patient who needs leech therapy. Antibacterial agents can be determined by the resistance pattern of the bacterial flora of regional H. medicinalis.

Symbiosis of Aeromonas veronii biovar sobria and Hirudo medicinalis, the medicinal leech: a novel model for digestive tract associations

Hirudo medicinalis, the medicinal leech, is applied postoperatively in modern medicine. Infections by Aeromonas occur in up to 20% of patients unless a preemptive antibiotic treatment is administered. The associated infections demonstrate the need for a better understanding of the digestive tract flora of H. medicinalis. Early studies reported the presence of a single bacterial species in the digestive tract and suggested that these bacteria were endosymbionts contributing to the digestion of blood. In this study, we cultivated bacteria from the digestive tract and characterized them biochemically. The biochemical test results identified the isolates as Aeromonas veronii biovar sobria. This species identification was supported by sequence comparison of a variable region of the genes coding for 16S rRNA. In a colonization assay, a rifampin-resistant derivative of a symbiotic isolate was fed in a blood meal to H. medicinalis. The strain colonized the digestive tract rapidly and reached a concentration similar to that of the native bacterial flora. For the first 12 h, the in vivo doubling time was 1.2 h at 23 degreesC. After 12 h, at a density of 5 x 10(7) CFU/ml, the increase in viable counts ceased, suggesting a dramatic reduction in the bacterial growth rate. Two human fecal isolates, identified as Aeromonas hydrophila and A. veronii biovar sobria, were also able to colonize the digestive tract. These data demonstrate that the main culturable bacterium in the crop of H. medicinalis is A. veronii biovar sobria and that the medicinal leech can be used as a model for digestive tract association of Aeromonas species.

The failing flap in facial plastic and reconstructive surgery: role of the medicinal leech

OBJECTIVE

To review the use of the medicinal leech, Hirudo medicinalis, in salvaging the failing, venous-congested flap. A protocol for the use of leeches is presented. Four illustrative cases of failing flaps (pectoralis major, midline forehead, and temporalis) are presented.

STUDY DESIGN

Literature review comprised of MEDLINE search 1965 to present. Retrospective review of four cases involving the management of the failing, venous-congested flap.

METHODS

A retrospective review of four cases of failing, venous-congested flaps was performed.

RESULTS

The authors' experience, as well as the data from the reviewed medical literature, demonstrates the importance of early intervention in order to salvage the failing, venous-congested flap. Leeches are an immediate and efficacious treatment option.

CONCLUSIONS

1. Review of the literature indicates that the survival of the compromised, venous-congested flap is improved by early intervention with the medicinal leech. H medicinalis injects salivary components that inhibit both platelet aggregation and the coagulation cascade. The flap is decongested initially as the leech extracts blood and is further decongested as the bite wound oozes after the leech detaches. 2. When a flap begins to fail, salvage of that flap demands early recognition of reversible processes, such as venous congestion. The surgeon must be familiar with the use of leeches and should consider their use early, since flaps demonstrate significantly decreased survival after 3 hours if venous congestion is not relieved. In the four cases presented, a standardized protocol facilitated early leech use and provided for the psychological preparation of the patient, availability of leeches, and an antibiotic prophylaxis regimen. 3. The complications associated with leech use can be minimized with antibiotic therapy, wound care, and hematocrit monitoring. 4. The use of the medicinal leech for salvage of the venous-congested flap is a safe, efficacious, economical, and well-tolerated intervention.