1. INTRODUCTION:

Deep vein thrombosis (DVT) is a critical and potentially fatal medical condition characterized by the formation of a blood clot within the deep veins, predominantly in the lower extremities^1,2. As the third most common vascular disease following ischemic heart disease^3,4,5 and stroke⁶, DVT affects approximately 1.6 individuals per 1,000 annually, highlighting its significant public health impact⁷. The disease typically initiates in the deep calf veins, with thrombi extending proximally into the popliteal, femoral, and iliac veins. The distribution of clot locations varies, with distal veins accounting for 40% of cases, popliteal veins 16%, femoral and common femoral veins each 20%, and iliac veins 4%⁸.

DVT is often referred to as a "silent killer" because it frequently presents without noticeable symptoms, occurring in 40% or fewer cases^9,10,11,12. When symptoms do manifest, they usually include aching pain that worsens with muscle activity, minimal swelling in the affected limb, and tenderness along the vein. The calf is the most common site for thrombosis, making prompt recognition and diagnosis essential to prevent severe complications¹³.

The pathophysiology of DVT is primarily explained by Virchow’s triad¹⁴, which includes venous stasis, hypercoagulability, and endothelial injury. These factors disrupt normal blood flow and clotting mechanisms, facilitating thrombus formation. DVT can be classified into two main types: superficial vein thrombosis (thrombophlebitis)^15,16 and deep vein thrombosis (phlebothrombosis)¹⁷.

Effective management of DVT focuses on preventing thrombus propagation, preserving venous valve function, and reducing the risk of pulmonary embolism¹⁸. Treatment strategies typically involve a combination of conservative measures and pharmacological interventions. Conservative approaches include bed rest, leg elevation, and the use of elastic compression stockings to promote blood flow.

Pharmacological treatments encompass anticoagulants like heparin and warfarin, fibrinolytic agents such as streptokinase, and antiplatelet drugs like aspirin. Recent advancements in medical therapy, including the development of novel oral anticoagulants, have enhanced treatment efficacy and patient outcomes^19,20.

Early detection and preventive measures are crucial in managing DVT, especially in high-risk populations such as hospitalized patients undergoing medical or surgical treatments. Prophylactic strategies, including the use of compression devices and appropriate pharmacotherapy, play a vital role in reducing the incidence of DVT and its associated complications. Ongoing research and advancements in diagnostic techniques continue to improve the ability to identify and treat DVT effectively, thereby mitigating its substantial morbidity and mortality burden.

In Unani medicine, leech therapy has long been employed as an effective method of bloodletting to treat various conditions, including DVT^21,22. This therapy works on the principles of Tanqiya-e-mawad (evacuation of morbid humors) and Imala-e-mawad (diversion of humors). Through these processes, morbid humors and excess fluids are removed from the body, restoring the balance of the four primary humors, which are essential for maintaining overall health. The application of leech therapy for DVT can be linked to its ability to divert and expel morbid fluids, aiding in the resolution of thrombosis and enhancing blood flow.

The effectiveness of leech therapy is attributed to the pharmacological properties of leech saliva, which exhibits Mussakkin (sedative) and Muhallil (anti-inflammatory) actions. These properties not only help reduce inflammation around the thrombus but also provide pain relief, thus making it a holistic treatment for venous thromboembolism in Unani medicine.

2. Case Presentation:

A 65-year-old male presented to the outpatient department of HSZH Government Unani Medical Hospital, Bhopal, Madhya Pradesh, with primary complaints of calf pain, swelling over the left leg, and mild discoloration of the left leg, present for 30-40 days. The patient also reported difficulty in walking and standing, with pain at rest, which worsened upon exertion.

The patient was previously asymptomatic and had not sought medical care before this episode. His condition interfered with daily activities, and he preferred non-pharmacological treatment approaches.

Past Medical History:

No history of hypertension, diabetes, trauma, thromboembolism, or previous surgeries.

Clinical Evaluation:

The patient underwent clinical evaluation, which revealed the following:

· Blood Pressure: 130/80mmHg

· Pulse Rate: 80 beats per minute

· Hemoglobin (Hb): 12g/dL

· Bleeding Time (BT): 3minutes

· Clotting Time (CT): 6minutes

· Bowel Habit: Regular

· Urine Examination: 6-7times per day, normal color and frequency

· HbsAg: Non-reactive

· CVS: S1 and S2 heart sounds were heard, with no added sounds.

· CNS: The patient was conscious, well-oriented, with intact memory and intelligence.

On physical examination, swelling, tenderness, warmth, and mild discoloration were observed on the left leg. There was a restricted range of motion due to pain. The patient’s condition did not involve any previous surgical or traumatic history.

Diagnostic Imaging and Examination:

A Venous Doppler ultrasound revealed acute thrombosis involving the veins of the left lower limb, extending superiorly to the external iliac veins, confirming the diagnosis of Deep Vein Thrombosis (DVT).

Unani Diagnosis:

The patient's condition was diagnosed as Su'ul Mizaj Damawi (blood humor imbalance) leading to Dumm-e-Jamood (blood stagnation), correlating to DVT in modern terms. The obstruction of blood flow in the veins due to thrombus formation led to swelling, pain, and difficulty in movement.

3. THERAPEUTIC INTERVENTION:

Leech Therapy was chosen as the primary intervention. Additionally, Sharbat Faulad (a Unani formulation) was administered orally (10 mL twice daily after meals) to improve hemoglobin levels.

Leech Therapy Procedure:

The affected area was cleaned with soap and water, followed by sterile cotton drying. Six leeches were applied around the swollen and discolored area of the left leg, avoiding directly visible veins to minimize excessive bleeding. The leeches were allowed to feed for approximately 30 minutes per session, and this was repeated once weekly for 4 weeks. After each session, antiseptic dressing was applied to the wound, and the patient was advised to elevate the leg to reduce swelling.

Post-Procedure Care:

A Hammam (steam bath) was given to the affected limb to further stimulate circulation and aid in the healing process.

4. ASSESSMENT CRITERIA:

Weekly assessment was done using the Visual Analogue Scale to monitor the pain and after the completion of the Leech therapy, Venous Color Doppler was performed to track improvements in the blood flow and thrombus size.

5. RESULTS:

Outcome: Before the commencement of leech therapy, the patient reported a pain score of 8/10, indicating severe discomfort. After the first week of treatment, this pain score reduced to 6/10, accompanied by a mild decrease in swelling. The patient was able to walk 30 meters with less pain. As treatment progressed into the second week, the pain score further dropped to 4/10, with a notable reduction in swelling. The patient’s walking capacity improved significantly, allowing him to cover 60 meters without major discomfort during exertion.

By the third week, there was a marked improvement in overall mobility, with the pain score reducing to 2/10. The patient was now able to walk 130 meters, experiencing minimal discomfort and further reduction in swelling. Upon completion of the fourth week of therapy, the patient’s pain had almost completely resolved, with a score of 1/10 (Figure 2) and only mild discomfort during physical exertion. Swelling and discoloration had nearly disappeared, and the patient was able to walk 300 meters comfortably (Figure1).

Figure 1 Improvement in Walking Distance Over Time During Leech Therapy

Figure 2 Reduction in Pain Score Over Time During Leech Therapy

Following the conclusion of the leech therapy, a Venous Color Doppler Ultrasound of the left leg was performed to evaluate the effectiveness of the treatment. The imaging revealed a significant reduction in thrombus size, allowing for enhanced blood flow through the affected veins. Notably, the circulation in the external iliac veins and surrounding areas showed marked improvement, indicating a successful therapeutic outcome.

Follow Up:

After the completion of the 4-week leech therapy treatment, the patient was advised to follow up for a period of 2 months to monitor his recovery and prevent any recurrence of symptoms. During this time, the patient was asked to maintain regular physical activity, including walking exercises, and to adhere to the Unani lifestyle and dietary modifications recommended during therapy. The patient was scheduled for bi-weekly consultations, either in person or via telehealth, to assess his progress. During each follow-up session, the patient's pain levels, mobility, and any signs of swelling or discomfort were monitored. He was encouraged to gradually increase his walking distance while avoiding strenuous exertion.

At each follow-up, the patient reported no recurrence of pain or swelling, with sustained improvements in mobility. He continued to walk comfortably and experienced no adverse effects, confirming the success of the therapy.

6. DISCUSSION:

The successful management of Deep Vein Thrombosis (DVT) in this 65-year-old male through leech therapy highlights the efficacy of this ancient Unani treatment in addressing complex vascular conditions. The patient, who presented with severe calf pain, swelling, and discoloration in the left leg, experienced marked improvements over the course of a 4-week treatment regimen. The progressive reduction in pain and swelling, alongside the restoration of mobility, underscores the therapeutic potential of leech therapy as an effective, non-invasive alternative for DVT management.

Leech therapy's success in this case can be attributed to the unique biological actions of hirudin, the primary anticoagulant enzyme secreted by leeches. Hirudin inhibits the action of thrombin, thereby preventing the formation of fibrin clots and promoting the dissolution of existing thrombi. This naturally helps reduce blood stagnation, improve venous flow, and relieve the symptoms of venous congestion.

In addition to hirudin, leech saliva contains several bioactive compounds, such as calin and destabilase, which further enhance the breakdown of fibrin and improve microcirculation. These compounds helped reduce the size of the clot, restored blood flow in the affected veins, and resolved the patient's symptoms of swelling, pain, and impaired mobility. This aligns with modern vascular pharmacology, which supports the use of anticoagulants for thrombus dissolution, but with the added benefit of a targeted, localized approach provided by leech therapy.

Compared to conventional DVT treatments, which often rely on anticoagulants like warfarin or heparin, leech therapy offers several advantages. First, it provides a localized treatment with minimal systemic side effects, particularly for patients who may be at risk of bleeding complications. In this case, the patient was able to avoid the complications typically associated with long-term anticoagulant use, such as gastrointestinal bleeding or adverse drug interactions, while still achieving excellent therapeutic outcomes.

Moreover, the non-invasive nature of leech therapy makes it a highly appealing option for patients seeking alternative treatments that align with natural or traditional medicine principles. The absence of adverse reactions throughout the treatment course further highlights its safety and efficacy.

7. CONCLUSION:

This case study demonstrates that leech therapy is a highly effective, non-invasive alternative for the management of Deep Vein Thrombosis (DVT), offering significant therapeutic benefits without the risks associated with conventional anticoagulants. The leech therapy successfully reduced the thrombus, promoting natural healing and improved blood flow. This case underscores the potential of Unani regimenal therapies in the treatment of venous disorders, presenting leech therapy as a viable option in modern healthcare for conditions like DVT. The successful outcome advocates for further research into the broader application of traditional Unani methods, offering a complementary approach in managing complex vascular conditions.

8. CONFLICT OF INTEREST:

The authors of the paper declare to have no conflict of interest.

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