Anaphylactic shock by multiple hepatic hydatid cysts
The present case appears in the journal Annals of Allergy, Asthma & Immunology.

A 40-year-old woman with no relevant background, immediately after eating pizza (made with turkey, cheese, onion, tomato, buckwheat, and oregano) and eggplant with baked cheese, presented with intense diaphoresis, generalized erythema, abdominal pain, dyspnea, foreign body sensation in the throat, and unconsciousness with urinary and fecal incontinence for 15 minutes.

She was administered 300 µg of intramuscular epinephrine, salbutamol aerosol spray, 5 mg of intravenous dexclorfeniramine, and 40 mg of intravenous methylprednisolone. She had complete resolution of symptoms and was discharged from the emergency department. Twenty-four hours before her event, she had taken an ibuprofen tablet.

The patient was then referred to allergy service. After the anaphylaxis episode, the patient had tolerated all foods except the eggplant. An allergological study was then performed that included skin prick test (milk, galactose-α-1,3-galactose, β-lactoglobulin, egg, ovoalbumin, ovomucoid, cheese, ham, tomato, eggplant—all negative), complete blood panel, biochemistry (including coagulation, liver and renal panel, electrolytes), and basal tryptase levels (2.3 µg/L), all within an acceptable range.

In-vitro testing showed total immunoglobulin E (IgE) of 2,538 kU/L, and specific IgE to Ascaris of 0.72 kU/L. Fasciola, amoeba, Cysticerci, and Trichinella IgG serology tests were negative; however, the result for Echinococcus granulosus was positive: 1 of 8,192. Abdominal echography and computed tomography demonstrated multiple hepatic focal lesions suggestive of hydatidosis, some with an exophytic component toward the subhepatic region, even reaching up to intestinal loops.

There were no extrahepatic lesions. Figure, shows it is even possible to distinguish the 3 layers of the cyst: 2 of them as part of the larvae and the third one, part of the host, acting as protection for the larvae to avoid the action of the immune system. This third layer protects against foreign-body reaction. The final diagnosis was anaphylactic shock by multiple hepatic hydatid cysts.

Typically, these patients would have symptoms associated with trauma or surgery. In tihs patient, however, due to the big size of the lesion, the anaphylaxis episode was probably due to small ruptures of the cysts that led to deposition of the larvae or leakage of some antigen into the circulation.

The patient was treated with 400 mg albendazole every 12 hours before a cyst-periquistectomy of the gallbladder and 3 segments of the liver. She received treatment with albendazole for 2 months after the surgery. After surgery, 2 years after the diagnosis, no relapses were recorded.

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