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1.  An unusual cause of severe dyspnea: A laryngeal live leech: Case report 
Highlights
•Leeches are the very rare cause of airway foreign body around the world.•Leeches can enter the human body when people swim in contaminative streams or drink infested water.•The leech was grasped with foreign body forceps with full length of more than 6 cm.
Introduction
Foreign bodies in the upper airways are one of the most challenging otolaryngology emergencies, leeches present a very rare cause of airway foreign bodies around the world.
Case report
A 6-year-old girl was referred to our otolaryngology department at a tertiary university hospital with a severe dyspnea and hemoptysis. Nasofibroscopy revealed a dark living leech in the supraglottic area which extends to the glottis. The patient was urgently admitted to the operating room, the leech was grasped and removed with a foreign body forceps with a full length of more than 6 cm. All symptoms were relieved post operatively and she was discharged one day later.
Conclusion
Leeches should be suspected as an airway foreign body in patients with a recent history of drinking from stream water. Prevention remains the best treatment for such cases based simply on hygiene measures like not drinking stream water directly and filtering drinking water before it is used.
doi:10.1016/j.ijscr.2016.12.007
PMCID: PMC5312483  PMID: 28213068
Dyspnea; Hemoptysis; Leech; Case report
2.  Otorrhagia bleeding due to leech bite 
Leeches are blood-sucking hermaphroditic parasites that attach to vertebrate hosts, bite through the skin, and suck out blood. When leeches feed, they secrete an anticoagulant (hirudin), which helps them get a full meal of blood. This is the first report of leech removal from external auditory canal. Previous leech involvement cases were explained in nasopharynx, larynx, pharynx, eye, and gastrointestinal tract. Prominent sign of all cases was active bleeding from the leech attachment site; that stopped with leech removal. A 24-year-old man was presented to Al-Zahra hospital with left otorrhagia and otalgia from 2 days ago. After suction of ear a small soft foreign body was seen in the external ear near the tympanic membrane, then the ear filled with glycerine phenice, the patient explained decreased movement of foreign body. Four hours later the bloody discharge stopped and otalgia decreased. After suction of clots, a leech was extruded from external auditory canal by alligator. Leech infestation is a rare cause of otorrhagia and should be suspected in the endemic region in all of unusual bleeding; it can be diagnosed and treated by exact inspection and removal.
doi:10.4103/2277-9175.96041
PMCID: PMC3507012  PMID: 23210074
Ear; external; leeches
3.  A rare case report of tracheal leech infestation in a 40-year-old woman 
Leeches are the very rare types of airway foreign body. Here we report a rare case of a 40-year-old woman with tracheal leech infestation. A 40-year-old woman presented 2-month history of dyspnea, occasional haemoptysis. There were foreign body sensation in throat, cough and hoarseness. Computed Tomography (CT) revealed some soft tissue shadow in the upper trachea. Eventually a 5 cm long living leech was smoothly removed from trachea by rigid bronchoscopy under sevoflurane general anesthesia. The airway leech infestation should be kept in mind especially in patients presenting with unexplained haemoptysis, dyspnea, hoarseness and a foreign body sensation in the throat and a history of drinking infested water from streams, pools and spring. General anesthesia might be necessary for the removal of the leech.
PMCID: PMC4238526  PMID: 25419405
Foreign bodies; leeches; trachea
4.  Leech in the Nose – an unusual cause of epistaxis 
Leech is an uncommon nasal foreign body, which can cause epistaxis. It is an aquatic segmental worm living in fresh water most commonly in tropical areas. Once it is attached in the nose, it will secrete an anticoagulant enzyme named hirudin, and that will result in continuous bleeding more than from a normal wound even after it is removed. We present a case of a live leech in the nose that caused unilateral epistaxis in a patient with a recent history of jungle trekking.
PMCID: PMC5408876
Leech; nose; epistaxis
5.  Vaginal Leech Infestation: A Rare Cause of Hypovolumic Shock In Postmenopausal Woman 
Background
Human leech infestation is a disease of the poor who live in rural areas and use water contaminated with leeches. Like any other body orifices, vagina can also be infested by leech when females use contaminated water for bathing and/or douching. Although this condition is very rare in postmenopausal women, it causes morbidities and mortalities.
Case Details
A 70 year old Para X (all alive) abortion I mother, postmenopausal for the last 20 years, presented with vaginal bleeding of 3 weeks duration to Gimbie Adventist Hospital, Western Ethiopia. On examination, she had deranged vital signs and there was a dark moving worm attached to the cervical os. She was admitted with the diagnosis of hypovolumic shock and severe anemia secondary to postmenopausal vaginal bleeding. After the patient was stabilized with intravenous crystalloids, the leech was removed from the vagina. She was then transfused with two units of whole blood and discharged with good condition on the 3rd post procedure day with ferrous sulphate.
Conclusion
Vaginal leech infestation in postmenopausal woman can cause hypovolumic shock and severe anemia. Therefore, in order to decrease morbidities from failure or delay in making the diagnosis, health care providers should consider the possibility of vaginal leech infestation in postmenopausal woman from rural areas and those who use river water for drinking, bathing and/or douching and presented with vaginal bleeding. In addition, the importance of using clean water and improving access to safe water should be emphasized.
PMCID: PMC4762978  PMID: 26949304
vaginal leech infestation; postmenopausal vaginal bleeding; Ethiopia
6.  Internal hirudiniasis in a hen (Gallus gallusdomesticus)-The first report in literature 
The leech is a blood sucking worm belonging to the class Hirudinea of the phylum Annelida. Leeches are commonly found in the waterland of temperate and tropical countries. Hirudiniasis, a rare condition with unusual symptoms, is caused by accidental introduction of leeches through natural orifices. In August 2011, a 1-year-old hen (Gallus gallusdomesticus) referred to private veterinary clinic in Iran with symptoms of severe respiratory distress, restless and inappetite. According to owner statement, the hen had a history of using spring water. After physical examination, black object was found attached to the internal mucous membrane of floor of mouth. The diagnosis was leech infection. The leech was removed by forceps without administration of drugsand detection, the hirudiniasis was caused by immature larvae of Limnatis nilotica (L. nilotica). According to author's knowledge, there is no report of Hirudiniasisin birds and the present case is the first report of internal hirudiniasis due to L. niloticain hen in literature.
doi:10.1016/S2222-1808(13)60046-8
PMCID: PMC4027299
Limnatis nilotica; Hen; Respiratiry distress; Iran
7.  Ocular leech infestation 
This case report describes a female toddler with manifestations of ocular leech infestation. A 2-year-old girl was brought to our outpatient clinic with a complaint of irritable crying after being taken to a stream in Hualien 1 day previous, where she played in the water. The parents noticed that she rubbed her right eye a lot. Upon examination, the girl had good fix and follow in either eye. Slit-lamp examination showed conjunctival injection with a moving dark black–brown foreign body partly attached in the lower conjunctiva. After applying topical anesthetics, the leech, measuring 1 cm in length, was extracted under a microscope. The patient began using topical antibiotic and corticosteroid agents. By 1 week after extraction, the patient had no obvious symptoms or signs, except for a limited subconjunctival hemorrhage, and no corneal/scleral involvement was observed.
doi:10.2147/OPTH.S79735
PMCID: PMC4356445  PMID: 25784786
leech; ocular foreign body; conjunctival reaction; pediatric ophthalmology
8.  THE LEECH AS A POTENTIAL VIRUS RESERVOIR 
Leeches, fed on swine infected with hog cholera, contained virus for as long as 87 days after their infective blood meals. In three instances, infected leeches apparently transmitted hog cholera virus to susceptible swine in the process of normal feeding. Myxoma virus persisted in leeches for as long as 154 days after the ingestion of a blood meal from rabbits with myxomatosis. Leeches fed consecutively, first on swine with hog cholera, and later on rabbits with myxomatosis, acquired both viruses. In such dually infected leeches, the hog cholera virus persisted for as long as 122 days and the myxoma virus for as long as 110 days, the longest periods tested. Leeches fed consecutively, first on rabbits with myxomatosis, and later on swine with hog cholera, acquired only the myxoma virus. Hog cholera virus could not be demonstrated in such dually fed leeches. Myxoma and hog cholera viruses appeared to be present in about equivalent amounts in the anterior and posterior thirds of the bodies of infected leeches. Myxoma and hog cholera viruses were present in the bloody gut contents of infected leeches but were not demonstrable in the body tissues of these leeches. It seems from the findings presented that leeches are not biological carriers of either myxoma or hog cholera virus but instead carry these two agents mechanically in their gastrointestinal tracts. In doing this, they appear to protect the viruses from various deleterious chemical and physical influences to which they would have been exposed in the open. It is speculated that leeches could play a role in nature in perpetuating the blood-borne viruses of certain diseases in which close association with bodies of fresh water is of epidemiological importance.
PMCID: PMC2136698  PMID: 13416474
9.  Epistaxis Due to Leech Infestation in Nose: A Report of Six Cases and Review of Literature 
The aim of this study is to report unusual cause of epistaxis due to leech infestation in nose in hilly area and its management. The study was carried out for a period of 4 years (2008–2012) in a secondary level hospital in hilly area of Darjeeling, West Bengal, India with data collected from the OPD and Emergency register of the patients. This retrospective case series consisted of six cases. All the cases presented with unilateral recurrent epistaxis and foreign body nose. Anterior rhinoscopy revealed fleshy greenish brown mobile mass inside the nasal cavity which was removed by forceps. The animate foreign body was identified as leech in all the cases. To conclude, in hilly areas leech infestation can present as animate foreign body in nose and it should be considered as important cause of epistaxis.
doi:10.1007/s12070-014-0728-0
PMCID: PMC4809819  PMID: 27066409
Nasal leech; Animate foreign body; Anterior rhinoscopic removal
10.  An Unusual Cause of Dysphagia: Live Leech in the Tongue Base 
Inhaled or ingested foreign bodies are relatively common causes of airway obstructions. They can be associated with significant morbidity and even mortality. Although various foreign bodies are aspirated or ingested, live leeches are rarely encountered. We reported a case of a live leech at the base of the tongue in an 18-year-old female patient with a history of unfiltered spring water drinking. We discussed the surgical technique and importance of anesthesia with this brief study.
doi:10.5152/tao.2015.1240
PMCID: PMC5782986
Larynx; dysphagia; leech; foreign body
11.  Leech management before application on patient: a nationwide survey of practices in French university hospitals 
Background
Leech therapy in plastic/reconstructive microsurgery significantly improves a successful outcome of flap salvage but the drawback is a risk of severe infection that results in a drop of the salvage rates from 70-80% to below 30%. We report the results of a national survey conducted in all the French university hospitals to assess the current extent of use of leech for medical practices in the hospital and to investigate maintenance, delivery practices and prevention of the risk of infection.
Methods
Data concerning conditions of storage, leech external decontamination, microbiological controls, mode of delivery and antibiotic prophylaxis were collected from all the French university hospitals in practicing leech therapy, on the basis of a standardized questionnaire.
Results
Twenty-eight of the 32 centers contacted filled the questionnaire, among which 23 practiced leech therapy, mostly with a centralized storage in the pharmacy; 39.1% of the centers declared to perform leech external decontamination and only 2 centers recurrent microbiological controls of the water storage. Leech delivery was mostly nominally performed (56.5%), but traceability of the leech batch number was achieved in only 39.1% of the cases. Only 5 centers declared that a protocol of antibiotic prophylaxis was systematically administered during leech therapy: either quinolone (2), sulfamethoxazole/trimethoprim (2) or amoxicillin/clavulanic acid (1).
Conclusions
Measures to prevent infectious complications before application to patient have to be better applied and guidelines of good practices are necessary.
doi:10.1186/s13756-018-0311-7
PMCID: PMC5800073
Leech therapy; Healthcare-associated infections; Practices of leech management; National survey
12.  Severe anemia due to pharyngeal leech infestation; a case report from Ethiopia 
BMC Surgery  2017;17:102.
Background
Leeches are rare blood-sucking endoparasites. Swimming in streams and ponds as well as drinking contaminated water are the major ways to acquire leeches.
Case presentation
A 6 year old boy who came with a history of hematemesis, frequent spitting of blood stained saliva, fatigue and anorexia to a rural hospital in Ethiopia. This was a rare case of severe anemia caused by a single leech infestation of laryngopharynx that required blood transfusion.
Conclusion
Leech infestation should be considered as a source of unexplained hematemesis, spitting of blood and severe anemia in rural areas.
doi:10.1186/s12893-017-0298-7
PMCID: PMC5639743  PMID: 29025407
Anemia; Leech; Larynopharynx
13.  Hamartoma of the Larynx: An Unusual Cause of Stridor 
Balkan Medical Journal  2014;31(4):349-351.
Background:
Hamartoma of the larynx is a very rare lesion, and the number of reported cases is limited. Signs and symptoms include stridor, changes in voice, eating and respiratory complaints. Stridor is a sign of upper airway obstruction. Patients presenting with stridor and severe respiratory distress necessitate urgent otolaryngologic evaluation.
Case Report:
Herein, we report a case of laryngeal hamartoma presenting with recurrent pneumonia and persistent stridor in a 7-month-old patient. He was admitted to hospital with the initial diagnosis of recurrent pneumonia and persistent stridor. Stridor was not responsive to cool mist, nebulised epinephrine or dexamethasone. Cervical computed tomography (CT) revealed a solid, nodular mass on the posterolateral wall of larynx. The mass was excised surgically. After surgical removal of the hamartoma, the child was relieved of the obstruction.
Conclusion:
We want to emphasise that patients presenting with persistent stridor and severe distress necessitate urgent otolaryngologic evaluation.
doi:10.5152/balkanmedj.2014.13184
PMCID: PMC4318408  PMID: 25667791
Hamartoma; infant; respiratory sounds; stridor
14.  Nasal leech infestation causing persistent epistaxis 
Foreign bodies in the nasal cavity are commonly encountered as a cause of epistaxis; however, nasal leech infestation as a cause of unilateral persistent epistaxis is very rare. Examination of nasal cavity revealed fleshy material in the left nostril, which was identified as leech. The leech was removed with the help of an artery forceps following irrigation of the left nostril with normal saline and adopting wait-and-watch policy. In developing countries, leech infestation as a cause of epistaxis should be suspected in patients with lower socioeconomic status or in those living in rural areas who give history of drinking polluted water from, or bathing in, stagnant ponds and puddles.
doi:10.4103/0974-2700.83875
PMCID: PMC3162716  PMID: 21887037
Epistaxis; foreign body; leech; nose
15.  External decontamination of wild leeches with hypochloric acid 
Background
Medicinal leech, Hirudo medicinalis, has been used in plastic and reconstructive surgery, to relieve venous congestion and to improve the microrevascularization of flaps. In many countries, wild leeches are still provided from local markets and utilised with antibiotic prophylaxies. In this research, results of identification of bacteria in the transport fluid is reported, oral and intestinal floras and the antibiograms of the identified microorganisms are investigated. Also, to avoid possible infections, the ability of hypochloric acid, a disinfectant, to suppress the relevant microorganisms without changing the life style and behavior of leeches in terms of sucking function, is investigated.
Methods
Bacterial identifications and antibiograms of oral and intestinal flora and transport medium were performed for 10 leeches. The optimum concentration of hypochloric acid which eliminated microorganisms without affecting the viability and sucking function of the leeches were determined by dilution of hypochloric acid to 100, 50, 25, 12.5, 6.25 ppm concentrations in different groups of 25 leeches. Finally, 20 leeches were applied atraumatically to the bleeding areas of rats, the duration of suction was determined and compared statistically between the leeches treated and not treated with hypochloric acid solution.
Results
Aeromonas hydrophilia was the most commonly identified microorganism and found to be resistant to first generation cephalosporins, frequently used in prophylaxis at surgical wards. In the next stages of the study, the leeches were subjected to a series of diluted hypochloric acid solutions. Although disinfection of the transport material and suppression of the oral flora of hirudo medicinalis were successful in 100, 50, 25, 12.5, 6.25 ppm concentrations; 12.5 ppm solution was the greatest concentration in which hirudo medicinalis could survive and sucking function was not affected significantly.
Conclusions
External decontamination of wild leeches with 12.5 ppm hypochloric acid enables bacterial suppression without causing negative effects on leech sucking function and life.
doi:10.1186/1471-2334-4-28
PMCID: PMC516442  PMID: 15329153
16.  The Relationship between Explanation and Patient Compliance in Hirudotherapy 
Archives of Craniofacial Surgery  2017;18(3):179-185.
Background
The use of leeches can effectively increase the salvage rate of flap congestion. However, the first reaction from patients and carers in using leeches in clinical fields is strong aversion. This can be due to the fact that development of our culture from agriculture to industrial society, coming across leeches became fairly rare. Also because of the biological traits that leeches carry; staying attached to a leg or other body parts of the host, sucking blood, and leaving wounds.
Methods
This study was conducted through questionnaires, divided into many subgroups. We scaled the compliance of the two therapies, with or without leech. Maximum scale of 10 showing no rejective response to the therapy and minimum scale of 0 showing the greatest rejective response.
Results
Overall subjects' compliance was improved after explaining the benefits of hirudotherapy. Irrelevant to the explanation, there was no significant difference in general compliance between male and female. Young-aged group and medical personnel or people studying medicine showed higher compliance over older-aged group and the general public.
Conclusion
In the terms of general social cognition, recognizing leech as a therapeutic material may not be welcomed at first, but provided with proper information and explanations, overall compliance of patients and carers can be improved and consequently result in superior outcomes in flap salvage.
doi:10.7181/acfs.2017.18.3.179
PMCID: PMC5647849
Surgical flaps; Bloodletting; Leeches; Patient compliance; Surveys and questionnaires
17.  Giant Anterior Cervical Osteophyte Leading to Dysphagia 
Korean Journal of Spine  2013;10(3):200-202.
Large anterior cervical osteophytes can occur in degeneration of the cervical spine or in diffuse idiopathic skeletal hyperostosis(DISH). Large osteophytes can produce otolaryngological symptoms such as dysphagia, dysphonia, and foreign body sensation. We describe a DISH patient with giant anterior cervical osteophyte causing chronic dysphagia and dysphonia. A 56-year-old man presented with increasing dysphagia, dysphonia, neck pain and neck stiffness. Physical examination of the neck showed a non-tender and hard mass on the left side at the level of C4-5. Radiography showed extensive ossification of anterior longitudinal ligament along the left anterolateral aspect of vertebral bodies from C2 to T1. The ossification was espe cially prominent at the level of C4-5 and linear breakage was noted at same level. Esophagogram revealed a filling defect along the pharynx and lateral displacement of the esophagus. Giant anterior cervical osteophyte was removed through the leftsided anterolateral cervical approach to the spine. Anterior cervical interbody fusion at C4-5 was followed by posterior cervical fixation using lateral mass screws from C3 to C6. After surgery, dysphagia and dysphonia improved immediately. One year later, cervical CT showed bone fusion at C4-5 bodies and no recurrence of osteophyte. DISH is a common cause of anterior cervical osteophyte leading to progressive dysphagia. Keeping this clinical entity in the differential diagnosis is important in patients with progressive neck stiffness, dysphagia or dysphonia. And surgical treatment of symptomatic anterior cervical osteophyte due to DISH should be considered with a solid fusion procedure preventing postoperative instability or osteophyte progress.
doi:10.14245/kjs.2013.10.3.200
PMCID: PMC3941753  PMID: 24757489
Anterior cervical osteophyte; Diffuse idiopathic skeletal hyperostosis; Dysphagia; Dysphonia
18.  Preventing Infective Complications following Leech Therapy: Elimination of Symbiotic Aeromonas spp. from the Intestine of Hirudo verbana Using Antibiotic Feeding 
Surgical Infections  2014;15(6):757-762.
Abstract
Background: Hirudotherapy is often used successfully in modern medicine, especially in plastic and reconstructive surgery. However, Aeromonas infections are the most common complications of post-operative leech application. Hence, prophylactic antibiotic administration is recommended before and during leech therapy. It has been confirmed that patient safety and achieving the desired therapeutic effect depend mainly on the microbiologic purity of the animals used. The aims of this study were to find a safe and practical way to eradicate symbiotic Aeromonas spp. occuring in the intestine of Hirudo verbana.
Methods: Leeches were fed artificially with 1.5 mL of sterile defibrinated sheep blood supplemented with ciprofloxacin (CIP) or cefotaxime (CTX), at bacteriostatic concentrations of 0.2 mcg/mL or 1.5 mcg/mL, and bactericidal concentrations of 20 mcg/mL or 50 mcg/mL, respectively. Bacteria were isolated from the leech intestines before and after feeding at different time intervals: 1, 7, 14, 21, and 28 d.
Results: Biochemical identification of bacterial isolates from water samples and intestines of H. verbana using the API-NE20 test showed that A. veronii biovar sobria was predominant. Bacteria belonging to the genus Aeromonas were detected in all control leeches. The results showed that optimum eradication of bacteria from leech intestines was obtained using 20 mcg/mL of CIP and 50 mcg/mL of CTX, which decreased the number of Aeromonas spp. to undetectable levels for two weeks after feeding in all treated leeches. A statistically significant reduction in the number of bacterial colonies (p<0.0001) was observed in leeches treated with bacteriostatic concentrations of CIP or CTX; no bacterial growth was found on the plates after only seven days of feeding with antibiotics. All water samples in which the leeches were kept before treatment were contaminated with Aeromonas spp., whereas these samples were negative after antibiotic feeding of animals.
Conclusions: All leeches were ready to take a blood meal after treatment, suggesting the possibility of using ciprofloxacin-treated or cefotaxime-treated leeches instead of chemoprophylaxis in patients undergoing hirudotherapy.
doi:10.1089/sur.2014.036
PMCID: PMC4268569  PMID: 24897173
19.  Morphological and molecular characterization of a new species of leech (Glossiphoniidae, Hirudinida): Implications for the health of its imperiled amphibian host (Cryptobranchus alleganiensis) 
ZooKeys  2014;83-101.
The hellbender (Cryptobranchus alleganiensis) is among the most intriguing and imperiled amphibians in North America. Since the 1970s and 80s, western populations of the Ozark and eastern subspecies in Missouri have declined by nearly 80%. As a result of population declines, the Ozark hellbender was recently federally protected as an endangered species, and the eastern subspecies was granted protection under CITES. Although habitat degradation is probably the biggest threat to hellbender populations, recent evidence suggests that pathogens including chytrid fungus and “flesh-eating” bacteria may also contribute to declines in Ozark hellbenders. Leeches, which are very common on Ozark hellbenders, have recently been implicated as possible vectors of disease among Ozark hellbenders but have not been described in eastern hellbenders or outside of Missouri and Arkansas. We discovered a population of leeches on eastern hellbenders in southwest Virginia and confirmed that the species of leech is within the genus Placobdella, but is morphologically and genetically distinct from all previously described leech species. We named the new species Placobdella appalachiensis sp. n. Moser and Hopkins, based on the mountainous region in which it was discovered. Our surveys over a three consecutive year period suggested that this leech species may be patchily distributed and/or have a narrow geographic range. We consistently detected leeches at one site (mean prevalence in 80 hellbenders = 27.5%; median intensity = 3.0 leeches per parasitized hellbender [range 1 – >250 leeches]) during three years of surveys, but we never found leeches in any of our other seven study sites in two streams (mean prevalence in 139 hellbenders = 0%). We found a significant positive relationship between hellbender body size and the intensity of parasitism, and we suggest the possibility that the behavioral ecology of adults leading up to reproduction may increase their encounter rates with parasites. We discuss the potential conservation implications of discovery of leeches in this stream, and make recommendations for future mitigation and monitoring efforts.
doi:10.3897/zookeys.378.6545
PMCID: PMC3935429  PMID: 24574854
Hellbender; leech; disease; parasite; Hirudinida; Glossiphoniidae
20.  Voice Disorders in Mucosal Leishmaniasis 
PLoS ONE  2014;9(7):e101831.
Introduction
Leishmaniasis is considered as one of the six most important infectious diseases because of its high detection coefficient and ability to produce deformities. In most cases, mucosal leishmaniasis (ML) occurs as a consequence of cutaneous leishmaniasis. If left untreated, mucosal lesions can leave sequelae, interfering in the swallowing, breathing, voice and speech processes and requiring rehabilitation.
Objective
To describe the anatomical characteristics and voice quality of ML patients.
Materials and Methods
A descriptive transversal study was conducted in a cohort of ML patients treated at the Laboratory for Leishmaniasis Surveillance of the Evandro Chagas National Institute of Infectious Diseases - Fiocruz, between 2010 and 2013. The patients were submitted to otorhinolaryngologic clinical examination by endoscopy of the upper airways and digestive tract and to speech-language assessment through directed anamnesis, auditory perception, phonation times and vocal acoustic analysis. The variables of interest were epidemiologic (sex and age) and clinic (lesion location, associated symptoms and voice quality.
Results
26 patients under ML treatment and monitored by speech therapists were studied. 21 (81%) were male and five (19%) female, with ages ranging from 15 to 78 years (54.5+15.0 years). The lesions were distributed in the following structures 88.5% nasal, 38.5% oral, 34.6% pharyngeal and 19.2% laryngeal, with some patients presenting lesions in more than one anatomic site. The main complaint was nasal obstruction (73.1%), followed by dysphonia (38.5%), odynophagia (30.8%) and dysphagia (26.9%). 23 patients (84.6%) presented voice quality perturbations. Dysphonia was significantly associated to lesions in the larynx, pharynx and oral cavity.
Conclusion
We observed that vocal quality perturbations are frequent in patients with mucosal leishmaniasis, even without laryngeal lesions; they are probably associated to disorders of some resonance structures (larynx, pharynx and nasal and oral cavities) or even to compensation mechanisms caused by the presence of lesions in the upper airways and digestive tract.
doi:10.1371/journal.pone.0101831
PMCID: PMC4108319  PMID: 25055046
21.  Globus Sensation Due to a Mobile Foreign Body in a 41-year-old Female 
Leech infestation could be associated with wide range of complications including epistaxis, stridor, hemoptysis, globus sensation, hematemesis, and vaginal bleeding. In the present case report. , we introduce a case of leech infestation in a 41-year-old female presenting with chronic globus sensation, stridor, vomiting and dysphagia later diagnosed with leech infestation. Therefore, leech bites might be considered as a differential. Diagnosis of globus sensation in the endemic rural areas where in unhealthy water from natural sources is consumed without taking required hygienic precautions.
doi:10.5681/jcvtr.2012.007
PMCID: PMC3825345  PMID: 24250978
Leech; Globus sensation; Stridor
22.  Postoperative respiratory difficulty due to asymptomatic anterior cervical osteophyte after brain tumor surgery: a case report 
Korean Journal of Anesthesiology  2016;69(6):640-643.
Anterior cervical osteophytes are commonly found in elderly patients, but rarely produce symptoms. When symptoms occur, they can range from mild symptoms of dysphagia, dysphonia, and foreign body sensation to severe symptoms of airway obstruction due to compression of the pharynx or larynx. We report the case of a 59-year-old man who underwent brain tumor surgery, and developed post-operative respiratory difficulty due to progressive pharyngo-laryngeal edema, requiring urgent endotracheal intubation, secondary to the presence of a previously asymptomatic anterior cervical osteophyte. It is paramount to recognize that asymptomatic anterior cervical osteophytes are a potential cause of life-threatening post-operative respiratory complications that can rapidly progress to life-threatening airway obstruction after surgeries in the prone position, especially in elderly patients.
doi:10.4097/kjae.2016.69.6.640
PMCID: PMC5133240  PMID: 27924209
Airway; Anterior osteophyte; Prone position; Respiratory difficulty
23.  Reproductive strategies of the kangaroo leech, Marsupiobdella africana (Glossiphoniidae) 
Highlights
•Unique leech in that it keeps it young inside a brood pouch, hence its name.•This leech is quite rare and only known from three localities.•First paper to show SEM pictures of Marsupiobdella spermatophore.•New info on its reproductive behavior.
Graphical Abstract
The Kangaroo Leech, Marsupiobdella africana, is a hermaphroditic organism, with insemination taking place by the planting of a spermatophore on another leech. Spermatophores are mostly planted on the anterior of the recipient leech, but not always. Several spermatophores may be planted by different leeches on a single recipient. The spermatophore consists of two side by side lobes. Within minutes from planting of the spermatophore, the contents are squeezed out and into the body of the recipient. Sperm are believed to find the way to the ova by following chemical cues. Kangaroo Leeches display advanced parental care by transferring fertilized eggs from the reproductive opening to a brood pouch on the ventral side. Fully developed leeches may copulate after detaching from the amphibian host Xenopus laevis, or from the Cape River Crab Potamonautes perlatus with which it maintains a phoretic association.
doi:10.1016/j.ijppaw.2015.01.005
PMCID: PMC4356878  PMID: 25830114
Cape River crab; Clawed frog; Leech; Reproduction; Spermatophore
24.  Laryngeal Leishmaniasis 
Summary
Introduction: Leishmaniasis is classified into three clinical presentations: visceral, coetaneous and mucocutaneous. The latter is usually secondary to hematogenous spread after months or years of skin infection and can manifest as infiltrative lesions, ulcerated or vegetating in nose, pharynx, larynx and mouth, associated or not with ganglionics infarction. Laryngeal involvement is part of the differential diagnosis of lesions in this topography as nonspecific chronic laryngitis, granulomatosis and even tumors of the upper aerodigestive tract presenting atypical evolution. Sometimes it is difficult for the correct diagnosis of Leishmaniasis, with description of cases in the literature were conducted improperly.
Objective: The objective of this study is to report a case of laryngeal Leishmaniasis addressing the difficulty of diagnosis, complications and treatment applied.
Case Report: A patient with pain throat, dysphagia, odynophagia, dysphonia and weight loss, with no improvement with symptomatic medication. At telelaringoscopy, infiltrative lesion showed nodular supraglottis. He underwent a tracheotomy for airway obstruction and biopsy with immunohistochemical study for a definitive diagnosis of laryngeal Leishmaniasis. The patient was referred to the infectious diseases that initiated treatment with N-methylglucamine antimoniate with satisfactory response to therapy.
Final Comments: Faced with a clinical suspicion of granulomatous diseases, it is essential to follow protocol laboratory evaluation associated with histological injury, to get a precise definition etiological without prolonging the time of diagnosis. Medical treatment for mucosal Leishmaniasis, recommended by the World Health Organization, was adequate in the case of laryngeal disorders, with complete resolution of symptoms.
doi:10.7162/S1809-97772012000400015
PMCID: PMC4432534  PMID: 25991983
Leishmaniasis; mucocutaneous Leishmaniasis; chronic granulomatous disease; larynx
25.  Leech Infestation: The Unusual Cause of Upper Airway Obstruction 
This paper presents a case of a 7 year-old child who presented with a 14-days history of blood stained saliva and shortness of breath of 3 days with signs of upper airway obstruction. Laryngoscopy revealed a blackish living foreign body in the proximal trachea. Under general anesthesia the leech was removed by applying forceps. I conclude that a high index of suspicion of leech infestation is required when faced with a child presenting with unexplained bleeding per mouth and signs of upper airway obstruction.
PMCID: PMC3613817  PMID: 23559840
Leech; Foreign body; Trachea; upper airway obstruction

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