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Hirudotherapy (Hirudo medicinalis)
The medicinal leech, Hirudo medicinalis, is being used to salvage compromised microvascular free-tissue transfers, replanted digits, ears, lips and nasal tips due to venous congestion (Mumcuoglu et al, 2007; Gileva & Mumcuoglu, 2012; Mumcuoglu, 2014).
Twenty-three patients (14 males and 9 females), 8-79 years old average: 35.9 years) with devascularized or amputated fingers, open wounds after accidents or surgical wounds after scar revision were included in the study. Of the 15 fingers treated by leech therapy, 10 fingers were saved (4 out of 9 replanted fingers and 6 out of 6 revascularized fingers), while out of 18 flaps treated by this treatment modality, 17 were salvaged (3 out of 4 free flaps and all 14 island and random flaps). Fifteen patients received 1-13 units of packed blood cells (average 2.9). The patients with revascularized or replanted fingers were treated in average of 2.5 days and each finger was treated with an average of 5.7 leeches. The 15 patients with flaps were treated in average of 3.4 days and each flap was treated with an average of 9.2 leeches. In conclusion, leech therapy should be considered as an integral part of the armamentarium used in reconstructive surgery. It improves greatly the success rate of the surgery in cases of post-operative venous congestions, allowing blood drainage until angiogenesis is established (Mumcuoglu et al. 2007).
Hirudotherapy has been complicated by infections caused by Aeromonas spp., which are considered endosymbionts of the leech. Leeches were treated by feeding them artificially with 100μg/ml ciprofloxacin using a 0.05 Mol arginine solution as a phagostimulant. Aeromonads were identified using the API 20NE system, and species determined by gyrB sequencing of two representative isolates. Aeromonas spp. were detected in 57 out of 80 control leeches (71.3%), but in none of the 56 leeches treated with ciprofloxacin. Treated leeches survived for up to four months. Tested weekly, leeches took human blood for at least 4 weeks after treatment and were all negative for Aeromonas spp. All water samples in which leeches were kept before treatment were contaminated with Aeromonas spp. but in none of the NaCl/arginine solutions that were used to feed antibiotic treated leeches. Two species were identified: Aeromonas veronii and Aeromonas media. Other environmental bacteria and some filamentous fungi were isolated from 28.6% of treated leeches that had taken a blood meal 1-4 weeks after treatment. Ciprofloxacin reduced the number of leech-associated aeromonads to undetectable levels for extended periods. Treated leeches were ready to take a blood meal after treatment, which show that it is possible to use leeches treated with antibiotics, with the ultimate aim of eliminating the need for systemic antibiotic prophylaxis for patients undergoing hirudotherapy (Mumcuoglu et al. 2009).
Recommendations for physicians for the treatment of decongested fingers and flaps in reconstructive plastic surgery have been given: A written informed consent should be obtained from the patient before hirudotherapy is initiated. The patients should be treated each day of leech therapy with anti-Aeromonas antibiotics. Leeches should be applied on the darker spots of the reattached body parts or flaps. Usually 1–10 leeches are used for each treatment, while at the beginning, the patient might need two or more treatments per day. Leech therapy is used until venous capillary return is established across the wound border by angiogenesis. Usually the treatment with leeches lasts for 2–6 days. Hematologic evaluations should be performed every 4 hrs and the patient has to receive blood transfusions when the hemoglobin level is lower than 8 g/ml. Signs of regional lymphadenitis, slight swelling, and pain of regional lymph nodes on the side of leech application and sub-febrile temperature can occur. Contraindications related to hirudotherapy include arterial insufficiency, hemophilia, hemorrhagic diathesis, hematological malignancies, anemia, hypotension, and sepsis. Leech therapy is not recommended in pregnancy and lactation and in patients with an unstable medical status, history of allergy to leeches or severe allergic diathesis, and disposition to keloid scar formation, as well as in those using anticoagulants and immunosuppressant (Mumcuoglu, 2014).

References:

Gileva, O.S. & K.Y. Mumcuoglu. 2013. Hirudotherapy. In: Grassberger, M., R.A. Sherman, O. Gileva, C.M.H. Kim & K. Y. Mumcuoglu (Eds). 2013. Biotherapy - History, Principles and Practice: A Practical Guide to the Diagnosis and Treatment of Disease using Living Organisms. Springer Pub., Heidelberg, pp. 31-76.
Mumcuoglu, K.Y. 2014. Other Ectoparasites: Leeches, Myiasis and Sand Flies. In: Manson’s Tropical Diseases. Farrar, J., Hotez, P.J., Junghanss, T., Kang, G., Lalloo, D. & N.J. White (Eds.), 23th. Edition, Elsevier, pp. 843-847.
Mumcuoglu, K.Y., Carole Pidhorz, Rivka Cohen, Andre Ofek & Howard A. Lipton. 2007. The use of the medicinal leech, Hirudo medicinalis, in the reconstructive plastic surgery. The Internet Journal of Plastic Surgery. Vol. 4 Number 2.
Mumcuoglu, K.Y., L. Huberman, R. Cohen, V. Temper, A. Adler, R. Galun & C. Block. 2009. Elimination of symbiotic Aeromonas spp. from the intestinal tract of the medicinal leech, Hirudo medicinalis using ciprofloxacin feeding. Clin. Microbiol. Infect. DOI:10.1111/j.1469-0691.2009.02868.x,Link
Mumcuoglu, K.Y. 2014. Recommendations for the use of leeches in reconstructive plastic surgery. Evidence-Based Complementary and Alternative Medicine, Vol. 2014, Article ID 205929, 7 pages, Link.
Tanyuksel, M. & K.Y. Mumcuoglu (Eds). 2015. Multidisciplinary and Biologically Based Natural Therapies – Biotherapy (Apitherapy, Hirudotherapy, Maggot Therapy and Ichthiotherapy). Multidisipliner Yaklaşımlı Biyolojık Temelli Doğal Tedaviler – Biyoterapi (Apiterapi, Hirudoterapi, Maggot tedavi ve İhtiyoterapi) (in Turkish). Meta Basım, İzmir.
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