foreign bodies constitute an uncommon cause of unilateral epistaxis in children . various inanimate and animate foreign bodies have been commonly found ; however , nasal leech infestation as a cause of epistaxis is very uncommon , and only a few cases have been reported till date . leech endoparasitism is extremely rare in urban areas but is frequent in endemic rural areas . sometimes patients with nasal leech infestation may have persistent epistaxis which may be difficult to control . a 7-year - old girl presented to the emergency room at the rural health center with history of nasal stuffiness for 4 weeks along with history of persistent bleeding from the left nostril for 3 days which frequently soaked her handkerchief in the form of small drops . she gave history of marked irritation in the left nostril , associated with difficulty in breathing when right nostril was occluded . she complained of having a sensation of a moving object in the left nostril and was repeatedly picking her left nostril . she had been prescribed xylometazoline nasal drops and oral pseudoephedrine ; however , these did not result in improvement . she did not give history of inserting any foreign body in the nostril , fever , runny nose or similar episodes of epistaxis in the past . physical examination examination of the nasal cavity revealed a soft fleshy material bulging into the left nostril close to the inferior turbinate . attempt was made to pull it out with the help of an artery forceps ; however , being a slimy structure , it repeatedly slipped from the grip of artery forceps and appeared to be tightly stuck to the inferior turbinate . after making a few attempts , the lower part of this fleshy material could be disentangled , and it was found to be moving . at this stage , it was identified as leech infesting the left nostril . since repeated attempts to dislodge the leech by artery forceps failed , irrigation of the left nostril with normal saline was done and it was decided to wait and watch . after a few minutes , it could be easily dislodged with the help of artery forceps . hematological investigations revealed hemoglobin to be 7.6 g / dl ; and total leukocyte count , 9,800/mm . after the procedure , she informed that she belonged to a very low socioeconomic stratum of society and had no access to safe drinking water and had to drink polluted water from an open pond and also take bath in it . she was advised not to take bath in polluted stagnant ponds or drink water from the open ponds . she was also advised to report immediately to the emergency department if similar complaints arose . orificial hirudiniasis is a condition in which a leech enters the body orifices , most often the nasopharyngeal region ; however , some cases of leeches infesting the urethra , vagina , rectum or even eyes have been reported . leeches are blood - sucking hermaphroditic parasites that attach themselves to the vertebrate hosts , bite through the skin and suck out blood . leeches have gained fearsome reputation by feeding externally on blood , often from human hosts . infestation occurs by drinking infested water from , or taking bath in , stagnant streams , pools and springs . leech infestation may cause serious complications like airway obstruction , severe respiratory distress , hemoptysis or hematemesis . leeches attach to the tissue by two muscular suckers , use three teeth inside their anterior sucker for biting and blood is sucked into stomach by peristalsis . leeches can ingest large amounts of blood into their stomach , which may weigh 8 to 9 times their body weight , and may cause severe anemia in the host . because leech bites are painless , infestation may remain symptomless until a warning sign appears . epistaxis , nasal obstruction and sensation of a moving foreign body are common presenting complaints of leech infestation in the nose . the saliva of leech contains hirudin , which inhibits thrombin in the clotting process ; and histamine - like substances cause continuous bleeding by causing vasodilatation . leech infestation primarily occurs in tropical areas such as mediterranean countries , africa and asia . cases of nasal leech infestation have been reported from various parts of india , pakistan and nepal . direct removal of leech might be difficult because of its powerful attachment to the nasal mucosa and its slimy and mobile body . these include a ) anterior rhinoscopy along with suction ; and b ) wait - and - watch policy  water is taken in a kidney tray and placed with water level 1 cm below nasal vestibule . in a comparative study of these two methods of treatment of nasal leech infestation , the method involving a wait - and - watch policy was found to be a better technique . as soon as leech is seen coming out from the nasal vestibule towards the water , it is caught with artery forceps and gently pulled out . the removal is faster with the former technique ; however , it is associated with more bleeding and pain . the method involving a wait - and - watch policy is a better technique and causes less pain and less blood loss , but it is more time consuming . besides this irrigation with strong saline , vinegar , turpentine oil or alcohol may be used for removal of leech . it can also be detached by applying 30% cocaine , 1:10,000 adrenaline or dimethyl phthalate . leech endoparasitism as a cause of nasal stuffiness and epistaxis is very rare . due to the presence of anticoagulant in the saliva of leech , , rhinoscopy is generally required for diagnosis ; however , it may not be possible in an emergency setup , as in our case . hence high index of suspicion is required in a patient presenting with unilateral epistaxis who gives history of drinking polluted water from , or bathing in , ponds and puddles .
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 .