A 6 year-old Ethiopian girl was brought to hospital by her mother with severe weakness. She had moderate mental impairment with difficulties in language and oral comprehension.

She had become progressively weaker over the last few months, being initially unable to run, later to walk, and finally she could hardly make minimal physical efforts. She had not had fever or any other systemic or digestive symptom.

Her family lived in a rural Ethiopian area, located above 2500 metres, where they usually drank freshwater from natural river pools and their staple food was ingera (teff) and vegetables.

Physical examination showed mental impairment. She had marked mucosal pallor (see image) and regular tachycardia with a systolic panfocal murmur grade II/VI. No organomegaly was present and the limbs were normal.

Haemoglobin was 3g/dL with a reduced MCV. White blood cells and platelets were normal. Basic biochemistry was normal. The colour of the faeces was normal.

Thin blood thin film was normal except for the presence of small erythrocytes. No blood parasites were detected.

Stool parasites tests (x3) showed the presence of Ascaris lumbricoides eggs and Entamoeba spp. cysts.

Given this information, what is your differential diagnosis and what method would you recommend to confirm the diagnosis in a setting where endoscopic procedures are not available?

Severe anaemia in the tropics could be due to several causes. Diseases such as malaria, babesiosis or visceral leishmaniasis can cause severe anaemia. Hookworm infestation (Ancylostoma duodenale or Necator americanus) is a common cause of iron deficiency anaemia. Sickle cell anaemia can produce recurrent haemolytic episodes. Chronic malnutrition or any other pathology within the gastro-intestinal tract that produces bleeding can lead to severe anaemia.

However the clinical clue in this case is the knowledge of her alimentary habits, in particular the origin of the drinking water. In low flowing rivers and natural pools, leeches are frequently present. Ingestion of leech-infested water can lead to infestation of the upper digestive tract and nasopharynx.

Limnatis nilotica attaches to mucosae and secretes an anticoagulant (huridin) that permits the suction of large quantities of blood. On occasions patients can have epistaxis, haematemesis or haemoptysis.

Leeches suck blood and grow within the organism but usually the patient or family is able to remove them when they are situated in the oral cavity or in any other accessible location. Those located in the oesophagus should be removed by means of an endoscopic procedure.

In our patient the leech was located in the oral cavity, but due to her communication problems she had not complained about its presence, which hindered the diagnosis. A manual extraction was performed, obtaining the organism showed in the image.