Acute acalculous cholecystitis following extended administration of nirmatrelvir/ritonavir for persistent SARS-CoV-2 infection.

Immunocompromised patients with hematologic malignancies, particularly those treated with anti-CD20 antibodies such as rituximab and obinutuzumab, are known to be at risk of prolonged infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Prolonged administration or combination therapy with antiviral medications reportedly yields favorable outcomes in these patients. However, knowledge regarding the adverse events associated with such therapeutic approaches is limited. Herein, we report a case of acute acalculous cholecystitis (AAC) following extended administration of nirmatrelvir/ritonavir (NMV/r) in a 68-year-old Japanese man with persistent SARS-CoV-2 infection. The patient had received obinutuzumab and bendamustine for follicular lymphoma and was diagnosed with coronavirus disease 2019 (COVID-19) approximately one year after treatment initiation with these drugs. Subsequently, he was admitted to a different hospital, where he received antiviral drugs, monoclonal antibodies, and steroids. Despite these interventions, the patient relapsed and was subsequently transferred to our hospital due to persistent SARS-CoV-2 infection. Remdesivir administration was ineffective, leading to the initiation of extended NMV/r therapy. One week later, he exhibited elevated gamma-glutamyl transpeptidase (GGT) levels, and one month later, he developed AAC. Cholecystitis was successfully resolved via percutaneous transhepatic gallbladder drainage and administration of antibiotics. We speculate that extended NMV/r administration, in addition to COVID-19, may have contributed to the elevated GGT and AAC. During treatment of persistent SARS-CoV-2 infection with extended NMV/r therapy, patients should be carefully monitored for the appearance of findings suggestive of biliary stasis and the development of AAC.

[Infectious mononucleosis : an atypical cause of acute alithiasic cholecystitis]. / La mononucléose infectieuse : une cause atypique de cholécystite aiguë alithiasique.

The Epstein-Barr virus (also known as EBV), responsible for infectious mononucleosis, is a virus that infects the majority of the world's population. Infection occurs in several forms, most often asymptomatic, or as a fever accompanied by pharyngitis and lymphadenopathies. A rare complication of infectious mononucleosis is acute acalculous cholecystitis, an inflammation of the gallbladder characterized by ischaemia and severe cholestasis. The diagnosis of this pathology is made by imaging, but determining the cause may be tricky. We present here the case of acute acalculous cholecystitis in a 21-year-old woman. This case highlights a rare complication of EBV infection that is probably under-diagnosed, and demonstrates the usefulness of interpreting liver tests and leukocyte count in association with imaging findings.

Le virus d'Epstein-Barr (aussi appelé EBV), responsable de la mononucléose infectieuse, est un virus qui infecte la majorité de la population mondiale. L'infection se présente sous plusieurs formes, soit, le plus souvent, asymptomatique, soit avec une fièvre accompagnée d'une pharyngite et de lymphadénopathies. Une des rares complications de la mononucléose infectieuse est la cholécystite aiguë alithiasique, une inflammation de la vésicule biliaire, caractérisée par une ischémie et une cholestase importante. Le diagnostic de cette pathologie est réalisé par imagerie et la détermination de la cause peut s'avérer compliquée. Nous présentons ici le cas clinique d'une cholécystite aiguë alithiasique chez une jeune femme de 21 ans. Ce cas nous permet de mettre en lumière une complication rare de l'infection par l'EBV, probablement sous-diagnostiquée, et démontre l'utilité d'interpréter les tests hépatiques ainsi que la formule leucocytaire en relation avec les résultats d'une imagerie.

Hepatitis C Virus-Associated Acalculous Cholecystitis and Review of the Literature.

Acute acalculous cholecystitis (AAC) is an infrequently encountered clinical condition associated with high morbidity and mortality. Viral infection associated AAC is rare, but it is most commonly associated with Epstein-Barr virus, cytomegalovirus, dengue virus, hepatitis A, hepatitis B, human immunodeficiency virus, disseminated visceral varicella-zoster virus infection, Zika virus, and hepatitis C. We report on a patient who was first diagnosed with a chronic hepatic C infection and subsequently with acalculous cholecystitis.

Hepatitis A and hepatitis E virus co-infection with right pleural effusion, ascites and acute acalculous cholecystitis. A case report.

Hepatitis A and hepatitis E are the leading causes of acute viral hepatitis in developing countries due to our poor sanitary conditions, both spread by fecal-oral route or through contaminated water and food. Being both self-limiting diseases, they are usually benign but may present with atypical clinical findings. A 32 year-old female with right pleural effusion, ascites and acalculous cholecystitis during the course of HAV and HEV co-infection is reported. Clinical improvement was observed with conservative management. As far as we know, this is the first case described of a patient with these three complications in the background of a hepatitis A virus and hepatitis E virus co-infection.

[A Case of Acute Acalculous Cholecystitis During Infectious Mononucleosis Caused by the Epstein-Barr Virus in a Young Woman].

Infection with the Epstein-Barr virus (EBV) is a common disease and is mainly asymptomatic during childhood, whereas infectious mononucleosis with clinical signs such as fever, pharyngitis, lymphadenopathy and hepatosplenomegaly often occurs in adolescents and adults with primary infection. Acalculous cholecystitis has been reported as a rare complication. We report herein a case of acalculous cholecystitis accompanied by infectious mononucleosis by EBV, which was treated successfully by medical treatment. A 33-year-old woman who had been admitted by fever, pharyngitis and lymphadenopathy developed a right upper quadrant pain, that was diagnosed as acalculous cholecystitis based on an imaging study. Antibiotic treatment did not resolve the symptoms, and surgical intervention was considered. We diagnosed her as having infectious mononucleosis based on a typical physical presentation and seropositivity for the EBV viral capsid antigen, suggesting that the acalculous cholecystatis might have been a complication of the EBV infection. After the administration of glucocorticoid and acyclovir, the patient became afebrile and the abdominal pain disappeared. Though acalculous cholecystitis rarely accompanies infectious mononucleosis caused by EBV, clinicians should be aware of this complication to avoid unnecessary cholecystectomy.

Acalculous cholecystitis or biliary dyskinesia for Epstein-Barr virus gallbladder involvement?

We present two patients with Epstein-Barr virus (EBV) infection related to gallbladder involvement. Such an association is already known as EBV induced acalculous cholecystitis, diagnosed on the basis of ultrasonographic findings. In our patients, radioisotopic cholescintigraphy was also performed and it showed that gallbladder was visualized in both patients in contrast to that what can be observed in cases of cholecystitis. However, the value of ejection fraction was compatible with biliary dyskinesia. We, therefore, consider that impaired gallbladder contractility in EBV infection cases may actually represent biliary dyskinesia and not acalculous cholecystitis taking into account the radioisotopic findings and the self limited course of the disorder.

Hepatitis A virus infection associated with bilateral pleural effusion, ascites, and acalculous cholecystitis in childhood: a case report.

BACKGROUND: Acute hepatitis A infection is common among children in developing nations. The clinical presentation in children is usually asymptomatic and anicteric, and it is a self-limiting infection. Rarely, it can be associated with extrahepatic complications such as pleural effusion, acalculous cholecystitis, and ascites. CASE PRESENTATION: An 8-year-old middle eastern child presented with abdominal pain, jaundice in the sclera, yellowish color of urine, and poor appetite. In the last two days, abdominal distension developed. After conducting diagnostic investigations, the child was diagnosed with HAV hepatitis associated with bilateral pleural effusion, acalculous cholecystitis, and ascites. He was managed conservatively with vitamin K supplementation and supportive parenteral fluids. After 4 days, clinical improvement was observed. CONCLUSION: Hepatitis A infections presented with extrahepatic manifestations like pleural effusion, acalculous cholecystitis, and ascites are very rare, especially in children. There have been some reports of these manifestations occurring in isolation, but for them to co-exist to our knowledge, this has only been reported in two cases in the literature, and this is the third case with all these three rare complications being presented simultaneously in a single child. Although HAV infection is an asymptomatic and self-limiting viral disease in childhood, it can manifest with rare extrahepatic complications, so pediatricians should be aware of this rare association to avoid unnecessary investigations.

Cytomegalovirus infection of the major duodenal papilla in a renal allograft recipient with severe biliary obstruction and acalculous cholecystitis.

Cytomegalovirus (CMV) can cause severe infections with serious consequences in renal transplant recipients. Disseminated CMV infections can affect almost every organ, but obstructive cholestasis and cholangitis, as a consequence of a CMV-induced papillitis, is extremely rare. We are reporting a rare case of obstructive cholestasis and cholecystitis due to CMV-related inflammation of the major duodenal papilla in a 60-year-old woman 3 months after renal transplantation. In addition, the patient suffered from a disseminated CMV infection with ulcerative esophagitis and gastritis. Because of the severe CMV infection, failure of the renal graft occurred. Obstructive cholestasis was resolved through internal stenting, and the progressive cholecystitis necessitated an emergency cholecystectomy. Following antiviral therapy with ganciclovir, the gastrointestinal ulcerations regressed and renal function was restored. Diagnosis of the CMV-related disease was established only in tissue samples, whereas standard serologic tests had failed.

[Acute gastrointestinal involvement in dengue disease by serotype 4: a case report and literature review]. / Compromiso gastrointestinal agudo en pacientes con dengue por serotipo 4: Comunicación de un caso y revisión de la literatura.

Dengue fever is the world's most important arboviral disease, presenting a wide clinical spectrum. We report for the first time in Peru, a case caused by dengue virus serotype 4 with significant gastrointestinal involvement (acute acalculous cholecystitis and acute hepatitis). In addition we carried out a review of the literature atypical presentation illustrating the importance of the characteristics of abdominal pain (right upper quadrant); presence of Murphy's sign, ultrasound, and liver enzymes levels, for appropriate diagnosis and clinical management.

Epstein-Barr Virus (EBV) acute acalculous cholecystitis in an immunocompromised adult patient: a case report and a literature review of a neglected clinical presentation.

Primary Epstein-Barr virus (EBV) infection may present with self-limiting abdominal involvement, characterized by hepatitis with mild elevation of aminotransferases, splenomegaly, and rarely with acute acalculous cholecystitis (AAC). Usually, treatment of EBV related AAC is symptomatic, without the need for surgery. Here, we describe a severe case of AAC occurring as the first manifestation of infectious mononucleosis in a young adult woman, receiving treatment with interleukin 6 receptor (IL-6r) inhibitor for rheumatoid arthritis (RA); moreover, we have performed a review of the literature on EBV-related AAC.

Acute Epstein-Barr infection presenting as cholecystitis with ascites.

A young female patient presented with features of ascites and cholecystitis. She was subsequently diagnosed with an acute Epstein-Barr virus infection. This is a rare presentation of a common infection. The patient was managed conservatively and the illness resolved within 6 weeks.

Acute acalculous cholecystitis with pericholecystitis in a patient with Epstein-Barr Virus infectious mononucleosis.

BACKGROUND: Acute acalculous cholecystitis is a rare complication of Epstein-Barr virus mononucleosis and involves thickening of the gallbladder wall. CASE REPORT: We describe the case of a 22-year-old woman with acute acalculous cholecystitis and pericholecystitis associated with Epstein-Barr virus primary infection. Surgical intervention was not performed, even though gallbladder perforation was suspected. The patient was treated conservatively with careful monitoring, including repeated ultrasonographic examinations. CONCLUSIONS: Epstein-Barr virus infections are usually self-limited, and surgical treatment of acute acalculous cholecystitis should only be considered when the ultrasonographic criteria persist on follow-up examinations or when they deteriorate. This is the first report of a severe course of acute acalculous cholecystitis with suspected gallbladder perforation associated with infectious mononucleosis.

Acute acalculous cholecystitis during the course of primary Epstein-Barr virus infection: a new case and a review of the literature.

OBJECTIVE: The aim of this study was to describe a case of acute acalculous cholecystitis occurring in the course of primary Epstein-Barr virus (EBV) infection. METHODS: The clinical features of the case were analyzed and compared to those of three other similar cases reported in the international literature. RESULTS: All cases occurred in European females with cholestatic hepatitis, presented with gallbladder wall thickening, and recovered uneventfully without the need for surgical intervention. CONCLUSIONS: Acute acalculous cholecystitis may occur during the course of acute EBV infection, especially in patients with cholestatic hepatitis. Clinicians should be aware of the possible involvement of the gallbladder during EBV infection to avoid unnecessary invasive procedures or the overuse of antibiotics.

[Acute acalculous cholecystitis as a complication of hepatitis A: report of 2 pediatric cases]. / Colecistite acuta acalcolotica in corso di epatite A: 2 casi pediatrici.

Acute acalculous cholecystitis (CAA) is very rare in children and it is usually related to infectious agents. We report 2 paediatric cases of CAA complicating hepatitis type A, with a favourable evolution with conservative treatment.

[Perforation of the acalculous gallbladder in a renal transplant recipient with CMV infection]. / Perforacion de vesicula biliar en el se-no de una infeccion por citomegalovirus en trasplante renal.

We report the case of a renal transplant recipient who developed acute acalculous cholecyscitis resulting in gallbladder perforation. At admission CMV antigenemia was negative. Emergency laparatomy was performed and showed the gallbladder to be infarted with a perforation. The abdominal cavity contained two litres of sterile bilious fluid. The pathological report showed frequent endothelial cells contained intranuclear and intracitoplasmatic inclusion (fig. 1). Treatment with Ganciclovir iv was started after diagnosis, but a computerized tomography scan demonstrated severe acute pancreatitis (grade E. Baltazar). The patient developed multiorgan failure and died on 19th day after surgery. Necropsy showed cytomegalic inclusions in pancreas (fig. 2), gastrointerstinal tract, lung and graft. A necroticing pneumonia with Mycotic spores and hiphae was seen. Aspergillus was also observed in myocardium (fig. 3).

A case of acalculous cholecystitis in the course of dengue fever in a traveller returned from Brazil.

BACKGROUND: Dengue is the second cause of fever after malaria in travellers returning from the tropics. The infection may be asymptomatic or it may manifest itself with fever only, some patients, however, may develop haemorrhagic symptoms and shock. MATERIALS AND METHODS: A 58-year-old woman came to the University Centre of Tropical Medicine in Gdynia after returning from a tourist journey to Brazil because of fever up to 39°C and malaise. She had lived in South America many years and then moved to Europe 3 years before hospitalisation. On admission physical examination revealed fever, dry mucosa, moderate hypotension and tachycardia. In the laboratory test results, leukopoenia, thrombocytopoenia and elevated transaminases were observed. On the second day of the hospitalisation, the patient reported epigastric pain, clinical examination revealed tenderness of the abdomen and macular rash on the skin of the trunk and thighs. The ultrasonography revealed an enlarged gallbladder with thickened walls, with hypoechogenic area surrounding it, a dilated common biliary duct of heterogenic echo, and some free fluid in the peritoneal cavity. An exploratory laparotomy was performed after 24 h because of the persisting strong abdominal pain and high fever. Intraoperatively, enlarged mesenteric lymph nodes were found, with no symptoms of gallbladder pathology. The postoperative course was uncomplicated and the positive result of immunochromatographic assay for dengue was obtained. RESULTS: The acalculous cholecystitis has been described in the course of various diseases and conditions. The typical symptoms include pain in the right hypochondriac region, fever, positive Murphy's sign, and abnormal liver function tests, which were observed in the presented case. Cholecystectomy is not usually indicated in the course of dengue (typically a self-limiting disease) due to a high risk of bleeding. CONCLUSIONS: The case provides a rationale for the inclusion of acalculous cholecystitis in the differential diagnosis in patients with abdominal pain returning from dengue endemic areas.