Medico

Case Report

ANAPHYLACTIC SHOCK DURING PERCUTANEOUS DRAINAGE OF HYDATID LIVER CYST

Peláez V, Kugler C, López L E, Del Carpio M, Correa D.
From the Departments of Critical Care and Radiology, CLINICA PASTEUR, NEUQUEN - ARGENTINA.

ADRESS REPRINT: Víctor Peláez, Department of Critical Care, Clínica Pasteur, Calle Rioja Nº 36 - CP 8300 - Neuquén, ARGENTINA. TEL: 054-299-4422470. FAX:054-299-4423953. E-mail vicpel@satlink.com

keywords: echinococcosis, anaphylaxis, puncture.

Anaphylactic shock is an unusual complication of hydatid cyst that was reported due to a spontaneous rupture, to surgical treatment and to percutaneous puncture. (9,15,16)
Percutaneous aspiration and treatment of hydatid cysts were considered an erroneous practice because of potential complications ofanaphylactic shock, spillage of hydatid fluid, and dissemination of the disease into the peritoneal space (3, 13). However, there have been instances of unintended percutaneous needle aspiration for diagnostic purposes without any side effects (11). Further successful percutaneous treatment of hydatid cysts has been reported (1, 2, 4, 5, 6, 7, 10, 12).
In May 1997, PAIR was offered as an alternativeto surgery to one female patient age 37 years with a hepatic hydatid cyst. The patient went to a doctor because she complained of right upper quadrant pain that was associated with a palpable mass.
The cyst was categorized acording to the Gharbi classification (8) in type III it was rounded and measured 90 mm in diameter and had well defined borders without any calcification or internal septa.Informed consent was obtained. To reduced the risk of seeding scoleces possibly spilled during the procedure, a brief course of albendazole was undertaken.
The patient had a intravenous catheter, and resuscitation equipment was available. With CT scan guidance, a fine needle was inserted into the cystic cavity by way of a trans-hepatic route, 100 ml of fluid was aspired, the needle wasobstructed during aspiration, probably because of membrane fragments.
Result of microbiologic examination of the aspirated fluid was positive for hydatid disease in this patient.
The cavity was filled with 80 ml of hypertonic saline (20% NaCl) as a scolecidal therapeutic agent. Control CT scans were obtained to check for the dilution of hypertonic saline and proper contact of hypertonic saline with allparts of the cavity.
After 15 minutes, 100 ml of fluid (the maximum possible amount of fluid), was reaspirated with a thick needle and it was withdrawn.
Approximately two minutes after that, the patient developed diffuse facial edema, and complained of progressive dizziness, chest tightness, and shortness of breath with 30 breaths per minute, stridor, diminished oxygen saturation to 93% on roomair, tachycardia and hypotension (systolic blood pressure, 60 mm Hg).
Normal saline fluid bolus was IV infused, in addition the patient received 50 mg of diphenhydramine (Benadryl), 125 mg of methylprednisone, 0,5 ml of epinephrine subcutaneous and oxygen to 100% via face mask. 10 minutes after, the dosis of epinephrine was repetead. Her condition gradually improved, and she was transferred tothe medical intensive care unit for 2 days, durin which time systemic corticoids and IV fluids were administered. Upon the patient`s discharge, her symptoms had completely resolved.
Anaphylactoid reactions, wich can be categorized as mild, moderate, severe, and fatal, are treated in a similar fashion to anaphylaxis. Epinephrine 1:1000 can be administered subcutaneously at a dose of 0,3-0,5 mg. IVfluid resuscitation with normal saline or Ringer lactate is used to combat hypotension. High flow oxygen should be administered, with intubation reserved for more severe cases. Aerosolized ( agonists such as albuterol and antihistamines such as diphenhydramien should be administered. IV steroids such as methylprednisolone are important in preventing recurrences because the effects of steroids...