A 24-year-old Bulgarian woman presented to the Emergency Department with a 2-hour history of acute onset epigastric pain which had migrated to the lower abdomen. She reported mild, intermittent, dull epigastric pain for the preceding year. There was no history of trauma or any past medical history of note. At presentation, she was haemodynamically stable with a pulse rate of 69 bpm and blood pressure of 108/36 mmHg. There was no respiratory compromise and O2 saturation was 98% on room air. Her temperature was 36.9°C. Palpation of the abdomen elicited significant epigastric and suprapubic tenderness with guarding and percussion tenderness. A faint erythematous rash was noted over her face and arms. Thirty minutes later she became shocked, tachypnoeic, and hypothermic at 35.2°C. The rash was more extensive, appeared urticarial and she had developed periorbital oedema. Her condition was stabilised with aggressive fluid resuscitation and intravenous steroids (Hydrocortisone 200 mg) and antihistamines (Chlorpheniramine 20 mg).\nInitial blood investigations were normal apart from a haemoglobin of 16.1 g/dL (12–16), glucose of 11.7 mmol/L (3–7), and lactate of 2.73 mmol/L (0.5–2.2). Liver and renal function tests were normal and there was no leucocytosis or eosinophilia. Venous blood gas demonstrated a pH of 7.287 (7.35–7.45), bicarbonate of 22.6 mEq/L (22–29), and base excess of −1.6 (−2 to 2) with normal pO2 and pCO2. Urine dipstick and β-HCG were negative. Contrast CT of her abdomen and pelvis revealed a large, well-defined area of low density occupying almost the entire left lobe of the liver with serpiginous enhancing strands within. Significant free fluid was noted throughout the abdomen and pelvis (see ). The appearances were highly suggestive of a ruptured hepatic hydatid cyst.\nThe decision was made to perform a diagnostic laparoscopy with a view to proceeding to laparotomy if required. Laparoscopy revealed a large ruptured cystic mass within the left lateral lobe of the liver, almost completely replacing the hepatic parenchyma (see ). There were also features of cholecystitis noted. Large amounts of free fluid were noted in all four quadrants. Removal of the cyst was achieved by way of an open left partial hepatectomy and the peritoneal cavity was washed out with hypertonic saline with a drain left in the subhepatic space. A cholecystectomy was also performed. Post-operatively she was managed in ITU and was commenced on Albendazole and Tazocin (Piperacillin/Tazobactam) with ongoing therapy for anaphylaxis. Praziquantel was also commenced but the patient subsequently became bradycardic to 30 bpm (although remained haemodynamically stable). No other cause was identified and resolved after discontinuation of Praziquantel. She was discharged 9 days post-operatively on reducing dose oral steroids and 3 cycles of Albendazole (4 weeks on, 2 weeks off). At follow-up, she remained well.\nHistology of the resected tissue confirmed the presence of a hyalinised, PAS-positive pseudocapsule (Brodie's capsule) with numerous scolices present, thus confirming the diagnosis of a hydatid cyst (see ). Histology of the gall bladder showed mild cholecystitis. No protoscolices or hooklets were seen in the drain fluid. Echinococcal serology (Hydatid ELISA) was positive.
A 37-year-old man presented in our emergency unit with severe abdominal pain and anaphylactic shock signs/symptoms, such as hypotension and allergic reaction.