A Recurrent Case of Adult-onset Still's Disease with Concurrent Acalculous Cholecystitis and Macrophage Activation Syndrome/Hemophagocytic Lymphohistiocytosis Successfully Treated with Combination Immunosuppressive Therapy.

We herein report the case of 21-year-old female diagnosed with adult-onset Still's disease (AOSD) three years earlier who presented with fever and right upper abdominal pain. She was diagnosed with acute acalculous cholecystitis (AAC) based on hepatic dysfunction, elevated C-reactive protein, and gallbladder wall thickening on abdominal ultrasound. Based on the presence of pancytopenia, hyperferritinemia, and hemophagocytosis by a bone marrow examination, she was diagnosed with macrophage activation syndrome (MAS)/hemophagocytic lymphohistiocytosis (HLH) which was refractory to glucocorticoid pulse therapy. The combination of intravenous cyclosporine A with glucocorticoids was able to successfully control the disease activity of AOSD-related AAC and MAS/HLH.

Acute acalculous cholecystitis in child with systemic juvenile idiopathic arthritis, unreported manifestation.

Acute acalculous cholecystitis is a gallbladder wall inflammation without gallstones. It was not reported before as a manifestation of systemic juvenile idiopathic arthritis. Here, we describe a 13-month-old boy presented with prolonged intermittent fever, skin rash, arthritis, serositis, and hepatomegaly. After workup, he was diagnosed with systemic juvenile idiopathic arthritis and acute acalculous cholecystitis based on an ultrasound abdomen showing thick gallbladder wall with free fluid. After treatment with three days of intravenous pulse methylprednisolone, he improved dramatically, and repeated ultrasounds showed normal gallbladder. This suggests that Acute acalculous cholecystitis can be a part of systemic juvenile idiopathic arthritis and hypothesised that surgical intervention can be avoided with the use of corticosteroids.

Brucellosis, an uncommon cause of acute acalculous cholecystitis: two new cases and concise review.

Acalculous cholecystitis etiologies while numerous, some of them are less-known such as brucellosis. In this report, we elaborate the clinical findings, investigations and management of two female patients presenting acalculous cholecystitis in whom diagnosis of acute brucellosis was retained. Both patients had fever, asthenia and abdominal tenderness. Laboratory results showed evidence of inflammation as well as hepatic cytolysis while cholestasis was noted in one patient. In both cases, ultrasound study and CT confirmed the presence of acalculous cholecystitis. Serology (tube agglutination test) led to the diagnosis of brucellosis. Diagnosis of brucellosis-related acute cholecystitis was established in both cases based on imaging findings as well as serology without resorting to cholecystectomy. Favourable clinical response to specific antibiotic therapy further supported our diagnosis as well as our decision to avoid surgery. Although few cases have been reported, brucellosis must be considered as a cause of acalculous cholecystitis, especially in endemic countries.

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.

Acute acalculous cholecystitis due to Fusarium species and review of the literature on fungal cholecystitis.

Fungal cholecystitis is an uncommon entity, and no cases of cholecystitis associated with mould infection have been reported. We present a case of acute Fusarium cholecystitis in a cytopenic patient with leukaemia who had disseminated fusariosis. We also review the published cases of fungal cholecystitis, which is most often caused by Candida species. Although it is rare, fungal cholecystitis should be part of the differential diagnosis of acute cholecystitis in high-risk patients with predisposing factors for opportunistic fungal infections.

A case of multi-drug resistant ESBL-producing Shigella sonnei acute acalculous cholecystitis and gastroenteritis in a returned traveller.

The first case of Shigella-associated acalculous cholecystitis is described. A 27-year-old woman presented to hospital with diarrhoea and acute acalculous cholecystitis one day after return to Australia from Vietnam. Her feces culture grew multi-drug resistant ESBL-producing Shigella sonnei and she improved with antimicrobial therapy and intravenous fluids.

Gallbladder ascariasis in Kosovo - focus on ultrasound and conservative therapy: a case series.

BACKGROUND: Ascaris lumbricoides is one of the most common intestinal infections in developing countries, including Kosovo. In contrast to migration to the bile duct, migration of the worm to the gallbladder, due to the narrow and tortuous nature of the cystic duct, is rare. When it does occur, it incites acalculous cholecystitis. CASE PRESENTATIONS: This case series describes a 16-month-old Albanian girl, a 22-month-old Albanian girl, a 4-year-old Albanian girl, and a 10-year-old Albanian boy. Here we report our experience with gallbladder ascariasis including clinical manifestations, diagnostic procedures, and treatment. Fever, diarrhea and vomiting, dehydration, pale appearance, and weakness were the manifestations of the primary disease. In all patients, a physical examination revealed reduced turgor and elasticity of the skin. Abdomen was at the level of the chest, soft, with minimal palpatory pain. The liver and spleen were not palpable. A laboratory examination was not specific except for eosinophilia. There were no pathogenic bacteria in coproculture but Ascaris was found in all patients. At an ultrasound examination in all cases we found single, long, linear echogenic structure without acoustic shadowing containing a central, longitudinal anechoic tube with characteristic movement within the gallbladder. Edema of the gallbladder wall was suggestive of associated inflammation. There were no other findings on adjacent structures and organs. All patients received mebendazole 100 mg twice a day for 3 days. They also received symptomatic therapy for gastroenteritis. Because of elevated markers of inflammation all patients were treated with antibiotics, assuming acute cholecystitis, although ultrasound was able to confirm cholecystitis in only two of our four patients. Since the length of stay was dependent on the primary pathology it was 7 to 10 days. At control ultrasounds on 14th day, third and sixth month, all patients were free of ascariasis. CONCLUSIONS: Gallbladder ascariasis should be considered in all patients presenting with abdominal pain, distension, colic, nausea, anorexia, and intermittent diarrhea associated with jaundice, nausea, vomiting, fever, and severe radiating pain. Eosinophilia, ova, and parasites on stool examination as well as an anechogenic tube with characteristic movement within the bile duct found on abdominal ultrasound are conclusive for diagnosis. Mebendazole is an effective drug for the treatment. Surgical treatment is rarely needed.

Acalculous Cholecystitis: Is an Elective Interval Cholecystectomy Necessary.

BACKGROUND: Acute acalculous cholecystitis (AAC) accounts for 5-10% of cases of acute cholecystitis. The advantage of interval cholecystectomy for patients with AAC is unclear. Therefore, a retrospective analysis of patients diagnosed with AAC at our institution was performed over a 5-year period. METHODS: Patients were identified via hospital coding using the keywords "acalculous cholecystitis, cholecystostomy and gall bladder perforation." Follow-up data was obtained by performing a retrospective review of the patients' hospital records. RESULTS: A total of 33 patients with AAC were identified and followed for a median period of 18 months. The median age at presentation was 70 (10-96) and American Society of Anesthesiologists (ASA) grade was 3 (1-5). Twenty-three patients (70%) were treated with antibiotics alone, 7 patients (21%) with percutaneous cholecystostomy and 3 patients (9%) with laparoscopic cholecystectomy. The 90-day mortality rate was 30% with significant correlation to comorbid status, as all deaths occurred in ASA grade 3-5 individuals (p = 0.020). Two patients (6%) developed recurrent AAC and were managed non-operatively. CONCLUSION: Antibiotics and cholecystostomy were the mainstay of AAC management, and comorbid status influenced related mortality. Our results suggest that it appears safe to avoid interval cholecystectomy in patients who recover from AAC, as they are typically high-risk surgical candidates.

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.

Successful treatment using corticosteroid combined antibiotic for acute acalculous cholecystitis patients with systemic lupus erythematosus.

There is no consensus of treatments for acute acalculous cholecystitis with systemic lupus erythematosus (SLE). The study was aimed to investigate the effect of the corticosteroid for these patients.A series of patients who were diagnosed as acute acalculous cholecystitis with SLE in the period from January 2012 to December 2016 at our hospital were included. They accepted 2 different conservative treatment strategies initially: the treatment using moxifloxacin (the antibiotic group), and the treatment using corticosteroid combined moxifloxacin (the corticosteroid group). Then clinical manifestations, laboratory features, and outcomes were analyzed.The study identified 22 women Han Chinese patients with the SLE history of 2.8 ±â€Š1.4 year. There was no significant difference in SLE history, Systemic Lupus Erythematosus Disease Activity Index-2000 (SLEDAI-2000), Systemic Lupus International Collaborating Clinics/American College of Rheumatology damage index (SLICC/ACR), hematologic examination results, and corticosteroid dosage between 2 groups. And there was no significant difference in the symptom of acute cholecystitis, duration of the symptoms, white blood level, and the thickness of gallbladder wall between 2 groups either. However, the SLEDAI-2000 of the corticosteroid group was lower than that of the antibiotic group (7.3 ±â€Š1.4 vs 10.7 ±â€Š3.0, P = .03), so was the SLICC/ACR (0.1 ±â€Š0.3 vs 0.3 ±â€Š0.5, P = .01). Moreover, total 11 of 12 patients were successfully treated in the corticosteroid group, only 1 patient got cholecystectomy because no improvement after conservative treatment. While 4 of 10 patients were successfully treated by moxifloxacin alone, 6 patients had to accept cholecystectomy in the antibiotic group. The rate of successful conservative treatment in the corticosteroid group was higher than that of the antibiotic group (P = .02). All patients were followed up at least 6 months, there was no statistical difference in the rate of recurrence of abdominal pain between 2 groups (P = .37).The corticosteroid plays an important role in the management of the acalculous cholecystitis patient with SLE, and it should be considered as a first line of treatment.

Acute acalculous cholecystitis in patients with systemic lupus erythematosus: A unique form of disease flare.

Objective We aimed to investigate the clinical features of acute acalculous cholecystitis (AAC) in patients with systemic lupus erythematosus (SLE). Methods SLE patients with AAC hospitalized in the Peking Union Medical College Hospital (PUMCH) from January 2001 to September 2015 were retrospectively analyzed. Their medical records were systematically reviewed. The diagnosis of AAC was based on clinical manifestations and confirmed by radiologic findings including a distended gallbladder with thickened wall, pericholecystic fluid and absence of gallstones. Results Among the 8411 hospitalized SLE patients in PUMCH, 13 (0.15%) were identified to have SLE-AAC. Eleven (84.6%) of them were female, with a mean age of 30.1 ± 8.6 years. AAC was the initial manifestation of SLE in four (30.8%) cases. Eleven (84.6%) patients complained of fever and abdominal pain, four (30.8%) had positive Murphy's sign and six (46.2%) had elevated liver enzymes. The median SLE Disease Activity Index was 8.0 (range 0-20.0) at the time of AAC. Other affected organs in SLE-AAC included kidney (11, 84.6%) and hematologic system (11, 84.6%), followed by mucocutaneous (seven, 53.8%), musculoskeletal (seven, 53.8%) and neuropsychiatric (two, 15.4%) systems. All patients received treatment of glucocorticoids and immunosuppressants but none underwent surgical intervention. During a median follow-up of 28 months (range, 2-320 months), 12 cases (92.4%) responded to treatment with no relapse and one patient (7.6%) died of septic shock. Conclusion Our study suggests that AAC is a relatively uncommon and underestimated gastrointestinal involvement of SLE that is often associated with active disease. For patients with AAC in SLE, treatment with aggressive glucocorticoids could result in a good prognosis.

Acute acalculous cholecystitis in systemic lupus erythematosus: a rare initial manifestation.

Acute acalculous cholecystitis is a very rare gastrointestinal manifestation in systemic lupus erythematosus and becomes rarer as an initial manifestation. There are only two cases reported. The authors report a 20-year-old black woman that presented acute acalculous cholecystitis revealed by abdominal computed tomography. During hospitalization, she was diagnosed systemic lupus erythematosus. Conservative treatment with antibiotics was performed with complete remission of the symptoms. Corticosteroid was started in ambulatory. Cholecystectomy has been the treatment of choice in acute acalculous cholecystitis as a complication of systemic lupus erythematosus. The patient responded well to conservative treatment, and surgery was not required. This case is unique in the way that corticosteroid was started in ambulatory care. We should not forget that the acute acalculous cholecystitis can be the initial presentation of systemic lupus erythematosus although its occurrence is very rare. Conservative treatment should be considered. Abdominal computed tomography was a determinant exam for better assessment of acute acalculous cholecystitis.

Acute acalculous cholecystitis in systemic lupus erythematosus: a rare initial manifestation / Colecistite aguda acalculosa no lúpus eritematoso sistêmico: uma manifestação inicial rara

ABSTRACT Acute acalculous cholecystitis is a very rare gastrointestinal manifestation in systemic lupus erythematosus and becomes rarer as an initial manifestation. There are only two cases reported. The authors report a 20-year-old black woman that presented acute acalculous cholecystitis revealed by abdominal computed tomography. During hospitalization, she was diagnosed systemic lupus erythematosus. Conservative treatment with antibiotics was performed with complete remission of the symptoms. Corticosteroid was started in ambulatory. Cholecystectomy has been the treatment of choice in acute acalculous cholecystitis as a complication of systemic lupus erythematosus. The patient responded well to conservative treatment, and surgery was not required. This case is unique in the way that corticosteroid was started in ambulatory care. We should not forget that the acute acalculous cholecystitis can be the initial presentation of systemic lupus erythematosus although its occurrence is very rare. Conservative treatment should be considered. Abdominal computed tomography was a determinant exam for better assessment of acute acalculous cholecystitis.

RESUMO A colecistite aguda acalculosa é uma manifestação gastrointestinal rara no lúpus eritematoso sistêmico e ainda mais rara como manifestação inicial. Foram descritos apenas dois casos até o momento. Os autores relatam o caso de uma mulher negra de 20 anos, com quadro de colecistite aguda acalculosa revelada pela tomografia computadorizada do abdome. Durante a hospitalização, a paciente foi diagnosticada com lúpus eritematoso sistêmico. Houve remissão completa dos sintomas após tratamento conservador com antibióticos. Iniciou-se tratamento com corticosteroides no ambulatório. Embora a colecistectomia seja o tratamento de escolha em casos de colecistite aguda acalculosa como complicação do lúpus eritematoso sistêmico, a paciente respondeu bem ao tratamento conservador; logo, a cirurgia não foi necessária. Este caso é único em razão do modo como o corticosteroide foi iniciado no atendimento ambulatorial. É importante lembrar que a colecistite aguda acalculosa pode ser a manifestação inicial do lúpus eritematoso sistêmico, embora sua ocorrência seja rara. Deve-se considerar a realização de tratamento conservador. A tomografia computadorizada do abdome foi determinante para que fosse feita uma melhor avaliação dacolecistite aguda acalculosa.

Atypical presentation of 'acalculous cholecystitis' with marked isolated hyperbilirubinaemia in patients treated for haematological malignancies.

Four patients diagnosed with haematological malignancies developed an isolated hyperbilirubinaemia following cytarabine- and anthracycline-based chemotherapy. The clinical picture was consistent with acalculous cholecystitis, but ultrasonography did not show the typical gallbladder wall thickening. All patients suffered from severe mucositis with neutropenic enterocolitis. We hypothesise that damage of the mucosa of the gallbladder induced by chemotherapy results in hyperpermeability of the mucosal barrier with bile leakage and isolated hyperbilirubinaemia.

[Assessment of the effectiveness of laser reflexotherapy in combined treatment of patients with chronic acalculous cholecystitis].

AIM: To study effects of laserpuncture in combined treatment of chronic non-calculous cholecystitis on motor function gallbladder, clinical symptoms. MATERIALS AND METHODS: 73 patients of chronic non-calculous cholecystitis were divided in to groups: 35 patients were received treated only by the means of standard therapy (the control group), 38 patients were received a course laserpuncture as part of complex treatment (the study group). RESULTS: Influence laser radiation on acupuncture points was found to induce positive therapeutic effect, such as: decrease the durations of clinical symptoms, correction of motor function gallbladder. CONCLUSION: Laserpuncture is an effective method of non-calculous cholecystitis treatment and can be included in relevant combined schemes.

Acute acalculous cholecystitis complicated with peritonitis caused by Lactobacillus plantarum.

Lactobacillus spp. rarely causes human disease. We report a case of a 57-year-old man with non-insulin-dependent diabetes and vascular disease admitted to our hospital with severe abdominal pain and fever. Signs of peritonitis were found upon examination. The patient underwent surgery, and a diagnosis of perforated cholecystitis with purulent peritonitis was made intra-operatively. A cholecystectomy was performed, and therapy with imipenem was initiated. Lactobacillus plantarum was isolated from bile and peritoneal fluid cultures 2 days later. The patient recovered well and was discharged on post-operative day 16 after 14 days of treatment with imipenem. To our knowledge, this is the second case reported of acute cholecystitis caused by Lactobacillus spp. This organism should be considered as a cause of biliary infections, especially in patients with underlying diseases. Correct identification is often difficult, but it is very important because these organisms are usually resistant to vancomycin and other antibiotics.

[The effectiveness of sulfate magnesium-calcium mineral water for the treatment of the patients presenting with chronic acalculous cholecystitis].

This paper was designed to report the results of investigations into the therapeutic effectiveness of "Kluchi" sulfate magnesiumcalcium mineral water used to treat 194 patients presenting with chronic acalculous cholecystitis and different types of biliary tract dysfunction. The control group was comprised of 92 patients who took a diet. It was shown, that mineral water "Kluchi" exerted well apparent beneficial action on the motor function of the gallbladder and the sphincter apparatus. Moreover, drinking the mineral water improved colloidal stability of bile. It is concluded that the therapeutic application of "Kluchi" sulfate magnesium-calcium mineral water results in the reduction of bile lihogenicity, produces anti-inflammatory and choleretic effects, and promotes normalization of the motor and tonic condition of the biliary tract.