Hydatid disease is a parasitic infestation caused by a tapeworm of the genus Echinococcus, and it is common in Mediterranean regions. Cystic lesions cause symptoms via compressing adjacent organs or may be totally silent. Morbidity is usually secondary to free rupture of the echinococcal cyst with or without anaphylaxis, infection of the cyst or dysfunction of affected organs. The cyst of Echinococcus granulosus is commonly located in the liver and frequently causes no symptoms. Anaphylactic reactions as a result of cyst perforation generally occur during interventions such as needle aspiration or open surgery; however, the spillage of cyst fluid with intravascular spread resulting from trauma may also trigger anaphylaxis, and rare case reports of this kind are present in the literature. We report the case of a 17-year-old man who was admitted to the public hospital with a sudden onset of nausea, vomiting and fainting. After a short period of intervention in the emergency department he died. As the cause of his sudden death was unknown, a forensic autopsy was carried out by the Forensic Council of Turkey. The autopsy revealed a macroscopically non-ruptured hydatid cyst in the liver and laryngeal oedema. In histopathological examination, two scolices in the pulmonary artery and inflammatory infiltration mainly composed of mast cells in the larynx were detected. Sudden death in this case was attributed to anaphylactic shock caused by intravascular spread of the cyst contents.

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P i c t u r e 1 . Ab d o mi n a l c o mp u t e d t o mo g r a m s h o wi n g a r e s i d u a l h e p a t i c l e s i o n i n t h e me d i a l s e gme n t o f t h e l e f t l o b e ( a r r o wh e a d ) a n d a mu l t i l o c u l a t e d , t y p i c a l s p o k e -wh e e l s h a p e d c y s t i c ma s s wi t h i n t h e l e s s e r s a c ( a r r o w) . PICTURES IN CLINICAL MEDICINE

Rabies, a fatal encephalitis of viral origin, is still a major health problem in the developing world. It begins, after exposure, with centripetal spread of the virus through peripheral nerves to the central nervous system. The virus proliferates there and spreads to the tissues via peripheral nerves. The diagnosis is not difficult when a nonimmunized patient presents with hydrophobia after a bite by a known rabid animal. Failure to identify an exposure and administer postexposure prophylaxis, however, can lead to a fatal outcome. We report 3 fatal cases of rabies in which the risk of developing rabies had not been seriously considered. Two had apparent dog bites, but 1 had a minor abrasion. Because rabies is uniformly fatal, possible exposure should be seriously considered in patients with mammalian bites or scratches.

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