Perioperative hypersensitivity to a vaginal cuff hemostatic agent in the setting of alpha-gal syndrome

Introduction: Alpha-gal syndrome (AGS) is an increasingly recognized immunoglobulin E (IgE)-mediated hypersensitivity disorder to mammalian-derived products that carries serious surgical implications if not considered perioperatively. As hemostatic agents are frequently utilized during gynecologic surgery, surgeons must be familiar with their components and potential adverse effects. Delayed hypersensitivity reactions (DHRs) to animal-derived surgical materials remain an underexplored area. Heightened surgeon awareness of appropriate hemostatic agent selection is critical, particularly in patients with AGS. Case Report: We present the perioperative course of a 42-year-old woman with known AGS who underwent an elective hysterectomy for abnormal uterine bleeding and dysmenorrhea. Intraoperatively, a bovine-derived hemostatic agent was applied to the vaginal cuff. Her postoperative course was complicated by a delayed presentation of pelvic hematoma, abscess formation, vaginal cuff dehiscence, and necrosis, requiring three additional surgeries. Notably, this patient demonstrated persistent eosinophilia without leukocytosis despite pathologically confirmed pelvic abscesses—an atypical finding suggestive of an immune-mediated process rather than isolated infection. Conclusion: The clinical course is consistent with a DHR superimposed on secondary infection following intraoperative exposure to a bovine-derived hemostatic agent in a patient with known AGS. This case highlights the potential severity, adverse outcomes, protracted hospital course, and resource utilization associated with inadvertent exposure to animal-derived surgical materials in patients with AGS. Delayed hypersensitivity reactions may not be immediately recognized, so surgeons should maintain heightened vigilance when operating on patients with known AGS and explore alternative hemostatic agents to prevent avoidable adverse outcomes.