Acute acalculous cholecystitis as the initial manifestation of systemic lupus erythematous: A case report

RATIONALE

Acute acalculous cholecystitis (AAC) is an extremely rare manifestation of systemic lupus erythematous (SLE). In previous reports, most of the patients were already diagnosed cases of SLE upon confirmation of AAC.

PATIENT CONCERNS

A 24-year-old female who initially presented with fever and acute right upper quadrant abdominal pain. She had no medical history.

DIAGNOSES

Abdominal ultrasonography and computed tomography (CT) showed gallbladder thickening with pericholecystic edema without gallstones or sludge, demonstrating acalculous cholecystitis. She revealed discoid rash on the both shin. Laboratory tests revealed pancytopenia. The titer of antinuclear antibody (ANA) was 1:1280. Anti-dsDNA antibody, anti-phospholipid antibody, anti-Sm antibody test, and proteinuria in 24 hours were positive. Both C3 and C4 were low. Echocardiography and chest CT showed pericardial effusion and pleural effusion. Using the 2019 European League Against Rheumatism/American College of Rheumatology (EULAR/ACR) classification criteria, the score was 31. We thought AAC of this case that was one of the initial manifestations of SLE.

INTERVENTIONS

The patient was treated with high-dose prednisolone (1 mg/kg) and hydroxychloroquine 400 mg.

OUTCOMES

After 4 days of administration of high-dose corticosteroid therapy, symptoms rapidly improved. After 35 days of the treatment, her symptoms and disease activity of SLE were markedly improved.

LESSONS

Although AAC being the initial manifestation of SLE is very rare, prompt diagnosis and management with corticosteroids precluded surgical intervention. Physicians need to be cognizant of AAC as a disease flare and as a rare initial manifestation of SLE.

Systemic Lupus Erythematosus-associated Acute Acalculous Cholecystitis Successfully Treated by a Corticosteroid Combined with Azathioprine

A 69-year-old Japanese woman was transferred to our hospital due to pancytopenia with a fever. She had Murphy's sign, and computed tomography showed pleural effusion and a swollen gallbladder without gallstones. We diagnosed her with systemic lupus erythematosus (SLE)-associated acute acalculous cholecystitis (AAC). Partly because her clinical and laboratory findings were not serious enough to warrant immediate surgical intervention, and partly because her poor general condition made her ineligible for surgery, surgical therapy was not selected. Corticosteroid therapy was performed with azathioprine, and the swelling in her gallbladder improved. As a conservative therapy for SLE-associated AAC, corticosteroid therapy combined with azathioprine might be beneficial.

Hemorrhagic Cholecystitis During Anticoagulant Therapy in a Patient With Systemic Lupus Erythematosus and Antiphospholipid Syndrome Undergoing Elective Laparoscopic Cholecystectomy

Hemorrhagic cholecystitis is a rare cause of abdominal pain that presents in traumatic settings, malignancy, and bleeding diathesis. Herein, we report a case of hemorrhagic cholecystitis during anticoagulant therapy in a patient with systemic lupus erythematosus (SLE) and antiphospholipid syndrome (APS) who underwent a laparoscopic cholecystectomy. A 61-year-old female presented with abdominal pain and melena during hospitalization for SLE. She had a history of SLE and APS before this episode. She was diagnosed with hemorrhagic cholecystitis by ultrasonography; computed tomography (CT); and duodenoscopy. CT revealed a distended gallbladder containing a hypodense material suggestive of blood. The duodenoscopy revealed blood-mixed bile appearing from the papilla. Following conservative treatment, hemostasis was confirmed, and an elective laparoscopic cholecystectomy was performed based on the diagnosis of hemorrhagic cholecystitis. The opening of the gallbladder revealed a large blood clot that gushed out, and multiple gallstones were also observed. The postoperative course was uneventful, and the patient has remained healthy without any complications.

So-called Acute Acalculous Cholecystitis in Macrophage Activation Syndrome

Acute acalculous cholecystitis (AAC) is a severe disease seen in critically ill patients, including those with autoimmune diseases. We herein report the case of a 41-year-old female who developed macrophage activation syndrome (MAS) accompanied by a recurrence of Kikuchi disease. Abdominal imaging revealed marked thickening of the gallbladder wall and pericholecystic fluid, typically found in AAC. Treatment with intravenous pulse methylprednisolone induced in a significant improvement in the gallbladder wall, resulting in no need for surgical intervention. We should consider that patients with MAS may therefore sometimes develop AAC and that early immunosuppressive therapy can be effective in AAC cases associated with rheumatic or autoimmune diseases.