Acute acalculous cholecystitis in malaria: a review of seven cases from an adult cohort

Evaluation and management of the surgical abdomen

PURPOSE OF REVIEW

The aim of this study was to describe important features of clinical examination for the surgical abdomen, relevant investigations, and acute management of common surgical problems in the critically ill.

RECENT FINDINGS

Lactate remains a relatively nonspecific marker of gut ischemia. Dual energy computed tomography (DECT) scan can improve diagnosis of bowel ischemia. Further evidence supports intravenous contrast during CT scan in critically ill patients with acute kidney injury. Outcomes for acute mesenteric ischemia have failed to improve over time; however, increasing use of endovascular approaches, including catheter-directed thrombolysis, may decrease need for laparotomy in the appropriate patient. Nonocclusive mesenteric ischemia remains a challenging diagnostic and management dilemma. Acalculous cholecystitis is managed with a percutaneous cholecystostomy and is unlikely to require interval cholecystectomy. Surgeon comfort with intervention based on point-of-care ultrasound for biliary disease is variable. Mortality for toxic megacolon is decreasing.

SUMMARY

Physical examination remains an integral part of the evaluation of the surgical abdomen. Interpreting laboratory investigations in context and appropriate imaging improves diagnostic ability; intravenous contrast should not be withheld for critically ill patients with acute kidney injury. Surgical intervention should not be delayed for the patient in extremis. The intensivist and surgeon should remain in close communication to optimize care.

Acalculous Cholecystitis in a Pediatric Patient With Plasmodium Falciparum Infection: A Case Report and Literature Review

Malaria has been associated with acute acalculous cholecystitis, a very uncommon complication in children. We present a 5-year-old girl, originally from Equatorial-Guinea, diagnosed with severe malaria with acute kidney injury, thrombocytopenia and acute acalculous cholecystitis. She was treated with intravenous quinine and clindamycin, plus cefotaxime and metronidazole with a full resolution without surgery.

Extracorporeal membrane oxygenation for refractory acute respiratory distress syndrome in severe malaria

Background

Severe malaria may be complicated by the acute respiratory distress syndrome (ARDS), which is associated with a high mortality. In the present report, a series of three cases of imported malaria complicated by refractory severe ARDS supported with extracorporeal membrane oxygenation (ECMO) is presented.

Methods

One female and two male adult patients (ages 39 to 53) were included. Two patients had Plasmodium falciparum infection and one patient had Plasmodium vivax and Plasmodium ovale co-infection. Anti-malarial therapy consisted in intravenous quinine (in two patients) and intravenous quinidine (in one patient), plus clindamycin or doxycycline.

Results

Despite lung protective ventilation, a conservative strategy of fluid management, corticosteroids (two patients), prone position (two patients) and inhaled nitric oxide (one patient), refractory severe ARDS supervened (PaO₂ to FiO₂ ratio 68) and venovenous ECMO was then initiated. In one patient, a bicaval dual-lumen cannula was inserted; in the two other patients, a two-site configuration was used. Two patients survived to hospital-discharge (duration of ECMO support: 8.5 days) and one patient died from nosocomial sepsis and multi-organ failure after 40 days of ECMO support.

Conclusions

ECMO support allowed adequate oxygenation and correction of hypercapnia under lung protective ventilation, therefore reducing ventilator-induced lung injury. ECMO referral should be considered early in malaria complicated by severe ARDS refractory to conventional treatment.

Acalculous cholecystitis occurring in the context of Plasmodium malariae infection: a case report

Introduction

Acalculous cholecystitis has been shown to occur in the context of malarial infection with Plasmodium vivax and Plasmodium falciparum and requires prompt diagnosis and treatment to prevent complications. To the best of our knowledge this is the first reported case of the disease occurring in a patient infected with Plasmodium malariae.

Case presentation

We report the first case of acalculous cholecystitis associated with Plasmodium malariae in a 59-year-old male Nepalese ex-Gurkha soldier. He presented with fever and vomiting and later developed right upper quadrant pain. Abdominal ultrasound and computed tomography scans confirmed acalculous cholecystitis for which he was treated medically with chloroquine, gentamicin and metronidazole. He made a full recovery.

Conclusions

Physicians should be aware that in addition to Plasmodium vivax and Plasmodium falciparum infections, acalculous cholecystitis can occur in the context of Plasmodium malariae infection. Mechanisms for this are discussed but further studies are needed to establish the etiology of this association.