Nasopharyngeal live leech infestation: an unusual cause of posterior bloody nasal discharge: two case reports.

Introduction and importance: Leech infestation is a rare but important cause of epistaxis and bloody posterior nasal discharge, particularly in individuals exposed to non-potable or infested water sources. Prompt diagnosis and removal are essential to prevent complications. Case presentation: We present two cases of nasopharyngeal leech infestation from endemic regions of eastern Iran. The first case involved a 42-year-old man from Khaaf, Razavi Khorasan Province, with intermittent epistaxis and bloody nasal discharge following river swimming. The second case involved a 35-year-old man with intellectual disability from Torbat-e Jam, Razavi Khorasan Province, who developed throat discomfort and bloody discharge after drinking non-potable water. In both cases, nasopharyngoscopy revealed a live leech attached to the mucosa and extending into the oropharynx. The leeches were successfully removed using Luc's forceps under endoscopic visualization without anesthesia. Both patients underwent complete head, neck, and airway examinations, including fibrolaryngoscopy, confirming no additional infestations. They were prescribed oral ciprofloxacin and remained asymptomatic at follow-up. Discussion: Leech infestation, though uncommon, should be considered in patients presenting with unexplained epistaxis, particularly those with a history of water exposure in endemic regions. Aquatic leeches secrete anticoagulants that cause persistent bleeding. Diagnosis requires careful nasopharyngoscopic evaluation. Endoscopic-guided removal is safe and effective in an outpatient setting. Prophylactic antibiotics, especially those covering Conclusion: Leech infestation should be included in the differential diagnosis of unexplained posterior epistaxis, particularly in endemic or low-sanitation areas. Early recognition and careful removal can prevent complications.