Acute acalculous cholecystitis due to infectious causes

Acalculous Cholecystitis as an Atypical Presentation of Viral Pericarditis: A Case Report

BACKGROUND Acalculous cholecystitis is a rare form of gallbladder inflammation that occurs without the presence of gallstones. It primarily affects critically ill patients and warrants prompt treatment given its association with high mortality. Pericarditis, an inflammation of the pericardium, typically arises from viral infections but can also be secondary to rheumatological, malignant, or bacterial causes. The concurrent presentation of both these conditions is rare and should prompt clinicians to investigate for a potential underlying cause. Previous case reports have shown that systemic lupus erythematosus, malignancies, and parasitic or bacterial infections are possible underlying causes of this dual presentation. CASE REPORT We describe a unique case in which acute viral pericarditis initially presented with clinical and imaging findings consistent with acute acalculous cholecystitis. A man in his 40s presented with epigastric pain and community ultrasound findings consistent with acalculous cholecystitis. As part of the workup, a CT scan showed an incidental finding of a pericardial effusion, and transthoracic echocardiogram revealed no evidence of cardiac tamponade. Despite treatment, the patient continued to spike fevers. Consequently, an extensive workup was performed, including pericardial and pleural biopsies, which were negative for rheumatological, bacterial, and malignant causes. After ongoing treatment with non-steroidal anti-inflammatory medications, the patient made a full recovery. CONCLUSIONS This case highlights the importance of recognizing acalculous cholecystitis as an atypical manifestation of acute viral pericarditis. When these 2 conditions occur together, identifying a possible underlying cause is paramount, as the management differs greatly. This case report is one of the few describing the presence of both conditions not due to a primary bacterial, malignant, or rheumatological cause. Viral illnesses can cause inflammatory responses leading to both conditions.

NK cell exhaustion in Wilson's disease revealed by single-cell RNA sequencing predicts the prognosis of cholecystitis

Metabolic abnormalities associated with liver disease have a significant impact on the risk and prognosis of cholecystitis. However, the underlying mechanism remains to be elucidated. Here, we investigated this issue using Wilson's disease (WD) as a model, which is a genetic disorder characterized by impaired mitochondrial function and copper metabolism. Our retrospective clinical study found that WD patients have a significantly higher incidence of cholecystitis and a poorer prognosis. The hepatic immune cell landscape using single-cell RNA sequencing showed that the tissue immune microenvironment is altered in WD, mainly a major change in the constitution and function of the innate immune system. Exhaustion of natural killer (NK) cells is the fundamental factor, supported by the upregulated expression of inhibitory receptors and the downregulated expression of cytotoxic molecules, which was verified in clinical samples. Further bioinformatic analysis confirmed a positive correlation between NK cell exhaustion and poor prognosis in cholecystitis and other inflammatory diseases. The study demonstrated dysfunction of liver immune cells triggered by specific metabolic abnormalities in WD, with a focus on the correlation between NK cell exhaustion and poor healing of cholecystitis, providing new insights into the improvement of inflammatory diseases by assessing immune cell function.

Unveiling the therapeutic role of Dachaihu decoction in acute cholecystitis: a comprehensive systematic review and meta-analysis of its efficacy and safety

Background

Dachaihu decoction (Dachaihu tang) plays a crucial role in treating acute illnesses. Recently, a significant number of clinical studies on Dachaihu decoction for acute cholecystitis (AC) have been published. This study was conducted to assess the efficacy and safety of Dachaihu decoction in patients with this condition.

Methods

To identify relevant randomized controlled trials (RCTs), eight databases and three clinical trial registries were searched from inception to 30 June 2024. Two researchers independently screened and extracted data from eligible studies using EndNote X9 and Microsoft Office Excel 2019. RoB 2.0 was used to assess the risk of bias in the included studies. Stata 17.0 was used for data analysis. Publication bias and its impact on result stability were evaluated using a funnel plot and the "trim-and-fill" method. The quality of evidence was graded using the GRADE assessment system.

Results

Thirty-three RCTs involving 2,851 participants were included. The treatment group demonstrated improved clinical efficacy (RR = 1.18; 95% CI = 1.13 to 1.24), significantly reduced length of hospital stay (MD = -1.78 days; 95% CI = -2.02 to -1.53), and the incidence of adverse events (RR = 0.31; 95% CI = 0.20 to 0.48). Additionally, there appeared to be reductions in the time for abdominal pain to resolve (MD = -1.92 days; 95% CI = -2.33 to -1.51), fever to disappear (MD = -1.52 days; 95% CI = -1.90 to -1.14), white blood cell count to return to normal (MD = -2.89 days; 95% CI = -3.32 to -2.46), alanine aminotransferase (ALT) levels (MD = -11.88 U/L; 95% CI = -15.29 to -8.47), aspartate aminotransferase (AST) levels (MD = -8.74 U/L; 95% CI = -9.76 to -7.72), neutrophil percentage (MD = -9.68; 95% CI = -11.33 to -8.03), TNF-α levels (SMD = -2.10 pg/L; 95% CI = -2.43 to -2.78), and certainty of evidence (moderate-to-low certainty).

Conclusion

Dachaihu decoction may be an effective botanical formula for managing AC and a lower incidence of adverse events. However, due to the substantial risk of bias and heterogeneity across the included studies, these findings should be interpreted with caution and require further validation through well-designed, high-quality trials.

Systematic Review registration

https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=573332.

Acute acalculous cholecystitis secondary to hepatitis A infection

Acute acalculous cholecystitis (AAC) of infectious origin represents a small percentage of all cases of cholecystitis. According to the literature, the most common pathogens include Salmonella typhii and Epstein-Barr virus (EBV). However, AAC has also been described as a rare complication in the context of other viral hepatitis infections, with only a few reported cases attributed to hepatitis A virus (HAV) infection. We present the case of a patient with AAC secondary to HAV infection, which resolved favorably with conservative management. We report the case of a 29-year-old male presenting with jaundice, abdominal pain, and fever lasting three days. Laboratory results revealed elevated transaminase levels with a cholestatic pattern and hyperbilirubinemia, predominantly direct bilirubin. Abdominal ultrasound showed a gallbladder with a thickened, heterogeneous, poorly defined, and disorganized wall, along with multiple enlarged perihilar lymph nodes and a positive Murphy's sign. Serological testing for hepatopathy revealed positive IgM antibodies for HAV, confirming the diagnosis of hepatitis A. Seven days later, follow-up testing demonstrated normalization of both laboratory parameters and ultrasound findings following resolution of the viral illness.

Acalculous Cholecystitis in COVID-19 Patients: A Narrative Review

Acute acalculous cholecystitis (AAC) represents cholecystitis without gallstones, occurring in approximately 5-10% of all cases of acute cholecystitis in adults. Several risk factors have been recognized, while infectious diseases can be a cause of cholecystitis in otherwise healthy people. Coronavirus disease 2019 (COVID-19) is caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and has spread worldwide, leading to an unprecedented pandemic. The virus enters cells through the binding of the spike protein to angiotensin-converting enzyme 2 (ACE2) receptors expressed in many human tissues, including the epithelial cells of the gastrointestinal (GI) tract, and this explains the symptoms emanating from the digestive system. Acute cholecystitis has been reported in patients with COVID-19. The purpose of this review is to provide a detailed analysis of the current literature on the pathogenesis, diagnosis, management, and outcomes of AAC in patients with COVID-19.

Clinical analysis of infectious mononucleosis complicated with acute acalculous cholecystitis

Objective

This study aimed to investigate specific clinical diagnostic methods for children with infectious mononucleosis (IM) complicated by acute acalculous cholecystitis (AAC).

Methods

We conducted a retrospective analysis of 171 cases of IM diagnosed in the infectious disease ward of Children's Hospital of Nanjing Medical University between January 2020 and December 2020. All IM patients underwent abdominal ultrasound examinations to assess the liver, gallbladder, and spleen. Fourteen patients with symptoms of AAC underwent a follow-up assessment one week later.

Results

The estimated incidence of AAC in hospitalized IM children was 8.2%. Both groups of patients presented with fever, abdominal pain, and eyelid edema upon admission. Characteristic radiological findings of AAC were observed, including gallbladder (GB) distention, increased GB wall thickness and increased common bile duct diameter. Analysis of laboratory results revealed no statistically significant differences in leukocyte, absolute lymphocyte count, CD3+, CD3 + CD4+, CD3+ CD8+, Aspartate Aminotransferase (AST), Alanine Aminotransferase (ALT), or Gamma-Glutamyl Transferase (GGT) levels between the AAC(+) and AAC(-) groups on admission. However, these parameters were not significant risk factors for AAC. After discharge, relevant indicators in non-AAC patients gradually decreased to normal levels, while those in AAC(+) patients did not show a significant decrease.

Conclusion

While cases of IM complicated by AAC are relatively uncommon, the utilization of abdominal ultrasound offers a reliable tool for confirming this diagnosis. Routine abdominal ultrasound examinations are recommended for IM patients to improve early detection and treatment of associated conditions.

Epstein-Barr in a Patient Presenting with Right Upper Quadrant Pain: A Case Report from the Emergency Department

BACKGROUND

Right upper quadrant abdominal pain and elevated cholestasis blood tests are usually associated with bacterial calculous cholecystitis. However, viral infections, such as Epstein-Barr virus (EBV) can also manifest with a similar clinical picture and is an important differential diagnosis.

CASE REPORT

This case report discusses a young woman presenting to the emergency department with acute right upper quadrant abdominal pain. The initial assessment revealed a positive Murphy's sign, elevated white blood count, and a cholestatic pattern on liver function tests, leading one to suspect bacterial calculous cholecystitis and initiating antibiotic therapy. However, clinical examination also revealed tonsillar exudates and differential white blood cell count revealed monocytosis and lymphocytosis rather than a high neutrophil count. The patient tested positive for EBV. Furthermore, ultrasound and magnetic resonance imaging revealed gallbladder wall edema with no gallstones, leading one to conclude that the clinical manifestation and laboratory results were due to an EBV infection. Antibiotic therapy was ceased and the patient did not require surgical intervention. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Calculous bacterial cholecystitis usually entails antibiotic therapy and cholecystectomy. It is important to be aware of the differential diagnosis of EBV, as it usually does not require either of these and resolves spontaneously.

Is conservative management a safe approach for patients with acute acalculous cholecystitis presenting with an acute abdomen?

Patients with acute acalculous cholecystitis (AAC) often present with acute abdominal symptoms. However, recent clinical studies have suggested that some patients with AAC and an acute abdomen, especially when caused by viruses or rheumatic disease, may not require cholecystectomy and that conservative treatment is adequate. Whether cholecystectomy is superior to conservative treatment for patients with AAC presenting with a severe acute abdomen is still uncertain. This was a case series study of AAC-related literature published between 1960 and 2022. In total, 171 cases (104 viral infection-associated AAC and 67 rheumatic disease-associated AAC) were included. The prognoses of patients receiving cholecystectomy or conservative treatment were compared. To account for confounding factors, etiological stratification and logistic regression were performed. The prognosis was similar for patients undergoing cholecystectomy and conservative treatment (P value .364), and virus infection-associated AAC had a better prognosis than rheumatic disease-associated AAC (P value .032). In patients with AAC caused by viruses or rheumatic disease, the acute abdomen can be adequately managed by conservative treatment of the underlying etiology and does not mandate surgical intervention.

HAV-induced acalculous cholecystitis: A case report and literature review

Hepatitis A virus (HAV) has some life-threatening extrahepatic complications, such as acute acalculous cholecystitis (AAC). We present HAV-induced AAC in a young female, based on clinical, laboratory, and imaging findings, and conduct a literature review. The patient became irritable, which progressed to lethargy, as well as a significant decline in liver function, indicating acute liver failure (ALF). She was immediately managed in the intensive care unit with close airway and hemodynamic monitoring after being diagnosed with ALF (ICU). The patient's condition was improving, despite only close monitoring and supportive treatment with ursodeoxycholic acid (UDCA) and N-acetyl cysteine (NAC).

Acute acalculous cholecystitis in a pediatric dengue hemorrhagic fever patient: A case report, lesson learned from limited resource setting

INTRODUCTION

Dengue fever (DF) is endemic in numerous regions of Indonesia with primary clinical features such as high fever as well as pullout of intravascular fluid and albumin leakage, which provokes pleural effusion, hypoproteinemia, and blood hemoconcentration. However, the incidence of abdominal pain as a clinical manifestation of DF, which refers to acalculous cholecystitis, is rare.

CASE PRESENTATION

An 11-year-old female was admitted to the to hospital with fever, headache, and myalgia. Blood examination resulted in low platelet coua nt and positive IgM Dengue antibody test. On the third day, the patient felt sharp abdominal pain. Abdominal ultrasound showed cholecystitis, cholestasis, pleural effusion, ascites, and laboratory finding showed increased C-reactive protein. The management was conservative and discharged at the 7th day.

DISCUSSION

The acalculous cholecystitis in Dengue Fever/Dengue Hemorrhagic fever (DF/DHF) is challenging in diagnose due to atypical presentations. Several proposed mechanisms are critical illness, including direct invasion of the gallbladder epithelial cells, vasculitis, stasis of biliary flow, obstruction of the biliary tree, ischemia, and sequestration. The actual mechanism of the dengue virus has been proposed that direct viral incursion of the gallbladder may yield edema and exudation. Abdominal ultrasonography is considered to diagnose acute acalculous cholecystitis (AAC) in children.

CONCLUSION

Understanding pathophysiology of the acalculous cholecystitis in DF/DHF patients and atypical presentation of sharp abdominal pain help physicians for early diagnosis and management both in monitoring and patient care management. Abdominal ultrasonography can help physicians to diagnose AAC.

Use of Gallbladder Width Measurement by Computed Tomography in the Diagnosis of Acute Cholecystitis

This study aimed to evaluate the diagnostic value of gallbladder width measurement with computed tomography (CT) in patients with acute cholecystitis. This retrospective case−control study was conducted between March 2016 and March 2020 at a tertiary emergency department. Of 310 patients, 254 patients with acute cholecystitis confirmed by surgery were compared with 254 patients diagnosed with other diseases (controls). In the acute cholecystitis group, the number of older patients with underlying illnesses was much higher (64% of men). Upon CT, the median (interquartile range [IQR]) gallbladder width was significantly longer in patients with acute cholecystitis (2.26 [1.82−2.78] cm vs. 3.73 [3.32−4.16] cm, p < 0.001). The optimal cut-off value of gallbladder width for differentiating acute cholecystitis was 3.12 cm, showing a sensitivity of 88% and specificity of 86%. In a multivariable analysis using a logistic regression model for diagnosing acute cholecystitis with CT findings (gallbladder width, length, stone, wall thickening, and pericholecystic fluid), a gallbladder width of ≥3.12 cm was significantly meaningful, even when adjusting for other variables (odds ratio 37.9; p < 0.001). Therefore, an increase in gallbladder width (≥3.12 cm) measured with CT can be a simple and sensitive diagnostic sign of acute cholecystitis, supporting the underlying pathophysiology of bile outflow obstruction.

Acalculous Cholecystitis in a Young Adult with Scrub Typhus: A Case Report and Epidemiology of Scrub Typhus in the Maldives

Scrub typhus is a neglected tropical disease predominantly occurring in Asia. The causative agent is a bacterium transmitted by the larval stage of mites found in rural vegetation in endemic regions. Cases of scrub typhus frequently present as acute undifferentiated febrile illness, and without early diagnosis and treatment, the disease can develop fatal complications. We retrospectively reviewed de-identified data from a 23-year-old woman who presented to an emergency department with complaints of worsening abdominal pain. On presentation, she appeared jaundiced and toxic-looking. Other positive findings on abdominal examination were a positive Murphey’s sign, abdominal guarding and hepatosplenomegaly. Magnetic resonance cholangiopancreatography demonstrated acalculous cholecystitis. Additional findings included eschar on the medial aspect of the left thigh with inguinal regional lymphadenopathy. Further, positive results were obtained for immunoglobulins M and G, confirming scrub typhus. The workup for other infectious causes of acute acalculous cholecystitis (AAC) detected antibodies against human herpesvirus 4 (Epstein–Barr virus), suggesting an alternative cause of AAC. Whether that represented re-activation of the Epstein–Barr virus could not be determined. As other reports have described acute acalculous cholecystitis in adult scrub typhus patients, we recommend doxycycline to treat acute acalculous cholecystitis in endemic regions while awaiting serological confirmation.