Review Article Complications of leech therapy Matineh Pourrahimi1, Mojtaba Abdi2, Roshanak Ghods3, 4* 1Student Research Committee, Faculty of Allied Medicine Branch, Iran University of Medical Sciences, Tehran, Iran 2Student Research Committee, School of Nursing and Midwifery Branch, Iran University of Medical Sciences, Tehran, Iran 3Research Institute for Islamic and Complementary Medicine, Iran University of Medical Sciences, Tehran, Iran 4School of Persian Medicine, Iran University of Medical Sciences, Tehran, Iran Article history: Received: Feb 06, 2019 Abstract Received in revised form: Objective: The principle of the use of leeches is associated with Aug 04, 2019 traditional medicine of many countries and its application has Accepted: Aug 24, 2019 different philosophies for use in different areas of the body. AJP, Vol. 10, No. 3, May-Jun Leeches, with all the benefits, can have dangers. 2020, 222-234. Materials and Methods: A review of complications of leech * Corresponding Author: therapy was done based on English articles indexed in the databases Tel: +98-9198535302 up to July 1, 2018. A strategic search has done independently by Fax: +98-21- 55613191 members of the research team and then all of the articles were [email protected] +categorized by subject. Results: Related articles were mostly case-reports. Complications Keywords: were divided into five categories including infection, allergy, Leech prolonged bleeding, migration, and others. Infection is the most- Leech therapy reported complication related to leech therapy and Aeromonas spp. Complication has the most participation in infections. Complementary medicine Conclusion: Leech therapy can be a therapeutic complementary method if the possible complications are managed properly. Please cite this paper as: Pourrahimi M, Abdi M, Ghods R. Complications of leech therapy. Avicenna J Phytomed, 2020; 10(3): 222-234. Introduction it has different philosophies for using in Leech is a kind of bloodthirsty different areas of the body (Whitaker et al., hermaphrodite. The genus Hirudo is known 2004; Hyson, 2005; Papavramidou and as Medicinal Leeches. In the saliva of this Christopoulou‐Aletra, 2009). small creature, there are more than Iranian traditional medicine scientists hundreds of bioactive compounds that are such as Avicenna and Abdul Latif injected to the host tissue during feeding Baghdadi also mentioned the effects of (Baskova et al., 2008; Mehlhorn, 2008; leech therapy in their books (Ibn-Sina, Porshinsky et al., 2011; Mann, 2013; 1593; AI-Baghdadi, 1942-1944). Wollina et al., 2016). The principle of Reviewing the sources of Iranian traditional Medicinal Leech Therapy (MLT) or medicine showed that leech therapy is used Hirudotherapy, is associated with for 125 different conditions, a wide variety traditional medicine of many countries and of diseases and disorders (Barzegar et al., 2015). AJP, Vol. 10, No. 3, May-Jun 2020 222 Complications of leech therapy With the advent of modern medicine, with the help of appropriate operators. After these little vampires were less used, but in identifying all the equivalent terms and all the late nineteenth century, a new use was the combinations of words, a search created for them in modern medicine (Lui strategy was written and a strategic search and Barkley Jr, 2015; Ghods et al., 2019). has done for using all of the mentioned The use of medicinal leeches for databases. The articles were probed intravenous congestion after reconstructive independently by members of the research surgeries has FDA approval (Deganc and team for increasing the accuracy and Zdravic, 1960; Rados, 2004). precision of the search. Finally, all of the The behavior of blood-sucking by an articles were merged into one database. In external parasite like leeches can have the appendix, the search strategy is different consequences because of piercing mentioned. the surface of the hosts' body for It should be noted that to prevent the loss penetration. The leech bite causes direct of the articles, the search was very connections between its body and the hosts' extensive and then, articles related to leech complications were extracted, also this body. A leech bite may also lead to death, search has been used in other research on though very rarely occurs. Therefore, leech the subject evidence of leech therapy therapy, with all the benefits, can have indication. dangers (Kose et al., 2008; Hildebrandt and Lemke, 2011; O’Dempsey, 2012). Papers selection The present study was conducted to In the first step, duplicate articles were review the findings of leech therapy removed. Then, valid articles were complications in articles to help clinicians separated from the news, the pages of with knowing its complications and public journals, newspapers and other non- preventing them. authoritative sources, as well as articles in the form of posters or lectures because of the internal validity of the research. In the Materials and Methods next step, the abstracts of the articles were Search strategy reviewed. Then, the full text of the articles The present study is a review of with our desired characteristics was complications of leech therapy. The extracted through access to the Central evidence presented in this article is Library of Iran University of Medical extracted from English articles indexed in Sciences. To get the full text of the databases such as Ebsco Host (All inaccessible articles through this library, academics Versions), Ovid, ProQuest, emails were sent to the authors of the PubMed, ScienceDirect, Scopus, Web of articles. Then, the full text of the articles Knowledge (Full Access) and Wiley and was studied and the final papers were Google Scholar (as a search engine). The selected for use in this study. Next, they articles related to our topic were gathered were categorized by subject. The EndNote and reviewed. The time frame for the search Ver.X7 software was used to manage of articles was up to July 1, 2018. articles. The paper flow is shown in Figure At first, the standard keyword and its 1. equivalents were extracted from the MESH. Then, using PubMed, Pilot search was Data extraction performed to discover more keywords for The findings of the articles and related writing search strategy by using "Leech", items together with their references were "Leeche", "Leech Therapy", "Leeching", separated in a category. After reading all the "Hirudinea", "Hirudineas", selected articles and searching the "Hirudotherapy" and their equivalents, bibliography of each paper, Findings were along with their expected combined forms, summarized in Table 1 and used in the article. AJP, Vol. 10, No. 3, May-Jun 2020 223 Pourrahimi et al. Figure 1. The papers flow; the process of extraction of articles related to leech therapy complication from the database of all articles about leech therapy. Results Giltner et al., 2013; Gonen et al., 2013; Twenty-five related articles, mostly case Wilmer et al., 2013) and 2 retrospective reports, were until 2018 (Table 1). Based on cohort studies (Kruer et al., 2015; Verriere the findings of Studies, articles were et al., 2016) were published in this field. categorized into five categories of Their results showed that Aeromonas spp. infection, prolonged bleeding, allergy, is most commonly observed in infections migration and other complications (Figure field (Table 2). Most usages of leeches were 2). in venous congestion and patients took antibiotic prophylaxis. Infection Six case reports (Schnabl et al., 2010; Wang et al., 2011; Bibbo et al., 2013; AJP, Vol. 10, No. 3, May-Jun 2020 224 Complications of leech therapy Table 1. Studies First author Study design Year Details Study Study number I1 Schnabl Case report 2010 Cause of leech therapy Venous congestion Patients 5 male patients with venous congestion Complications Infection with A. hydrophila and A. veronii biovar sobria Outcomes fluoroquinolone antibiotics I2 Wang Case report 2011 Cause of leech therapy The fibula osteomyocutaneous flap for mandible reconstruction Patients 1 male patient with ameloblastoma and undergo fibula osteocutaneous flap Complications Infection with ciprofloxacin-resistant A. hydrophila Outcomes The patient treated with cefepime but the flap necrotized and 8 months later the patient has been undergoing reconstruction surgery for another time. I3 Bibbo Case report 2013 Cause of leech therapy Venous congestion Patients 1 insulin-dependent diabetic male patient with venous insufficiency, morbid obesity, chronic lateral ankle wound, and a Charcot ankle deformity Complications Infection with A. hydrophila, A. veronii, Proteus Vulgaris, and Morganella morganii Outcomes Treated with parenteral antibiotics (Not Mentioned), operative debridement, negative pressure dressings, and hyperbaric oxygen therapy I4 Giltner Case report 2013 Cause of leech therapy Venous congestion at the distal portion of the flap Patients 1 female underwent surgery patient with the otocephalic mandibular syndrome Complications Infection with A. hydrophila and Morganella morganii(Both resistance to ampicillin-sulbactam and cefazolin and susceptible to cefepime and gentamicin) Outcomes The patient was treated with piperacillin-tazobactam (2.25 g iv. q8h) and metronidazole treatment (230 mg iv. q8h) was continued for 3 weeks. I5 GÖNEN Case report 2013 Cause of leech therapy Osteoarthritis of the knee Patients 1 female patient with osteoarthritis of the knee Complications Infection with Acinetobacter spp. Outcomes Treated with tigecycline (50 mg) after 21 days I6 Wilmer Case report