Kaya et al. Journal of Medical Case Reports 2011, 5:172 http://www.jmedicalcasereports.com/content/5/1/172 Page 2 of 3 Figure 1 Bleeding after leech bite. bleeding was active. Her varicose veins were explored under local anesthesia. The veins punctured by leech bite were dissected by operation. They were ligated with 4/0 Vicril Rapide sutures (Figure 2). After completing hemostasis, the skin was sutured with 3/0 prolene. Our patient was examined seven days after her operation. The wound was clear without any complication. Discussion H. medicinalis has two suckers, one in its anterior and one in its posterior region. They usually feed via the anterior suckers in a process that lasts about 20 to 40 minutes. They can suck 10-15 ml of blood and may increase their body size eight to 11 times. Leeches have different chemical agents within their bodies that are released when salivating (Table 1). Hiru- din is a proteolytic inhibitor that has an antagonistic Figure 2 Ligation of bleeding vessels performed in the emergency room. Table 1 Chemical substances produced by leeches Substance Hirudin Histamine-like substance Hyaluronidase Effect Anti-thrombotic effect Vasodilation Breakdown of connective tissue. effect to thrombin. The major action of thrombin is the conversion of fibrinogen into fibrin, which is a critical event in the coagulation process. Hirudin, by its inhibi- tory effect, causes a decrease in platelet aggregation. It is thought that the prolongation of bleeding after leech bite is mainly due to hirudin. Histamine-like substance is another protein that is found in the salivary cells of leeches. It causes vasodilation of the blood vessels. It increases the amount of blood sucked by a leech. Another enzyme, hyaluronidase, facilitates the break- down of connective tissue by disturbing hyaluronic acid. Beside these chemical agents, Munro et al. [2] described another substance found in the saliva of leeches called calin. It has a powerful action as an anticoagulant and mainly inhibits platelet aggregation. The persistent bleeding is likely the effect of the enzymes found in the saliva of leeches. Sustained bleeding may persist as long as seven days. Our patient had uncontrolled bleeding for about 18 hours. Leeches are commonly used in Turkey in medical treatment of venous congestion of the lower extremities. A diagnosis of leech bite can be made easily. Patients usually have a history of medicinal leech therapy. If a leech is found at the bite site, it can be removed with the use of table salt, vinegar or lignocaine solution. Bleeding after leech bite in different parts of the body has been reported [3-6]. Leech bite may be associated with morbidity such as serious bleeding and skin infec- tion. Anemia can often be seen with leech infestation. Erysipelas and skin abscess with Mycobacterium mari- num may also be seen in patients with leech bite. Skin wounds may heal with scar formation. Aeromonas hydrophila is a bacterium that can live with leeches symbiotically. It can cause infection after leech bite. Antibiotic prophylaxis in medicinal leech treatment may be recommended. Although it is rare, leech bite may also cause death [7]. Prolonged bleeding after leech bite should be treated seriously. Some bleeding may require transfusion due to loss of large amounts of blood. There are several meth- ods to treat prolonged bleeding after leech bite. Pressure with sterile gauze on the wound is the simplest method. In cases of sustained bleeding, sterile gauze soaked in a thrombin solution can be applied. Desmopressin (1-dea- mino-8-D-arginine vasopressin; DDAVP) has been reported as an effective agent in controlling bleeding in rats after hirudin infusion [8]. Our patient was treated