Acute severe cholecystitis with empyema presenting as a gallbladder mass, jaundice and Mirizzi Syndrome: A case report.

INTRODUCTION: Acute severe cholecystitis with empyema presenting as a gallbladder mass, jaundice and Mirizzi Syndrome (MS) is a complex surgical problem both diagnostically and in terms of management as it mimics both xanthogranulomatous cholecystitis (XGC) and gallbladder carcinoma. PRESENTATION OF CASE: A 48-year-old gentleman was referred to us with biliary colic and weight loss with ultrasound findings of gallstones. At subsequent follow-up he became deeply jaundiced with deranged liver function and a CT showing a gallbladder mass and dilated biliary tree. Follow-up MRCP suggested XGC and concomitant MS, but a malignant process could not be excluded. Pre-operative fine needle aspiration cytology (FNAC) at the time of percutaneous biliary drainage for his jaundice demonstrated XGC with no evidence of malignancy. Given the dense inflammation and a tense empyema at laparoscopy, he underwent a subtotal fenestrating cholecystectomy. The final histopathological diagnosis was acute cholecystitis. DISCUSSION: Our patient likely had unrecognised acute cholecystitis which progressed to a complex mass with empyema and type I Mirizzi Syndrome, ultimately resulting in severe obstructive jaundice mimicking gallbladder carcinoma. Given that a laparoscopic total cholecystectomy is dangerous in these cases of severe inflammation, a laparoscopic subtotal cholecystectomy has been shown to be a safe alternative to more invasive strategies and was successfully utilised in our patient. CONCLUSION: Acute severe cholecystitis with empyema presenting as a gallbladder mass, jaundice and Mirizzi Syndrome is a rare manifestation that requires adequate pre-operative work-up to exclude malignancy. Subtotal fenestrating cholecystectomy is a safe and effective alternative to open surgery in these cases of complex inflammation.

Pulmonary Artery Pseudoaneurysms in the Setting of Gout Polyarthropathy: A Case Report.

Pulmonary artery pseudoaneurysm is a dangerous pathology often missed as a differential and on imaging. With a 50% mortality rate early detection and intervention are critical to patient outcome, rendering diagnosis based on clinical grounds to be of paramount importance. A high index of suspicion should be placed on patients presenting with unprovoked hemoptysis, hemorrhage or hemothorax. Knowledge of the common causes of pulmonary artery pseudoaneurysms is also important; however, it is integral to note spontaneous occurrences in patients with no known risk factors. Herein, we report a case of an unprovoked pulmonary artery pseudoaneurysm in a 72-year-old male with no known risk factors or causes for the pathology. Additionally, we review the pathophysiology behind the potential association of polyarthritic gout as a cause of pulmonary artery pseudoaneurysms. To the best of our knowledge this is the first reported link between the two diseases, providing grounds to widen literature and increase diagnoses of pulmonary artery pseudoaneurysms.