ACALCULOUS CHOLECYSTITIS AND COVID-19. A CASE
REPORT
..................
Ana
María Pérez Murcia ¹
, Luisa Fernanda Amado ², Laura
Camacho ³
Abstract
Introduction.
COVID-19 (Coronavirus disease 2019) is mainly characterized by its
respiratory symptoms, but numerous clinical presentations have been
described with a recent increment in gastrointestinal manifestations.
Presentation of the case.
A 33-year-old, overweight man with no other known medical history,
consulted due to symptoms suggestive of biliary pathology and a system
review finding
of cough and dyspnea. He was taken to surgery due to the finding of AC
(Acalculous Cholecystitis)
and in the postoperative period, he presented respiratory distress,
identifying positive SARS-CoV-2
(Severe Acute Respiratory Syndrome Coronavirus 2), previous idiopathic
heart failure, and acute pulmonary thrombosis.
Discussion.
The presentation of AC with SARS-CoV-2 is infrequent. It does not
have an established clinical pattern and there are multiple confounding
factors that make it a diagnostic challenge, and even a distracting
factor for the diagnosis of COVID-19 and its complications.
Keywords: Acalculous Cholecystitis; COVID-19;
SARS-CoV-2.
..............
¹ Servicio de Medicina Interna, Hospital de San José.
Especialista Docencia Universitaria, Fundación Universitaria de
Ciencias de
la Salud.
² Servicio de Medicina Interna, Hospital de San José.
Residente, Fundación Universitaria de Ciencias de la Salud.
³ Calidad, Médico Hospitalario. Hospital de San José.
COLECISTITIS ACALCULOSA Y COVID-19.
REPORTE DE CASO
Resumen
Introducción. La COVID-19 (del
inglés Coronavirus disease 2019), se caracteriza principalmente por su
sintomatología respiratoria, pero se han descrito numerosas formas de
presentación con un aumento reciente de las manifestaciones
gastrointestinales.
Presentación del
caso. Varón de 33 años con sobrepeso y sin otros antecedentes
conocidos, que consulta
por sintomatología sugestiva de patología biliar y hallazgo a la
revisión por sistemas de tos y
disnea. Es llevado a cirugía por hallazgo de CA (Colecistitis
Acalculosa) y en el posoperatorio
presenta dificultad respiratoria identificando SARS-CoV-2 (del inglés
severe acute respiratory
syndrome coronavirus 2) positivo, falla cardíaca idiopática previa y
trombosis pulmonar aguda.
Discusión. La
presentación de CA con SARS-CoV-2 es infrecuente, no tiene un patrón
clínico establecido y sí múltiples factores de confusión que lo tornan
en un reto diagnóstico
e incluso un factor de distracción para el diagnóstico de la COVID-19 y
sus complicaciones.
Palabras clave: Colecistitis Acalculosa; COVID-19;
SARS-CoV-2.
..................
Introduction
To date, COVID-19 produced by the SARS-CoV-2,
has reported more than 400 million confirmed cases
and more than 5 million deaths around the world
according to the latest data from the World Health
Organization (1). Although its pathology is mainly
characterized by respiratory symptoms, numerous
forms of presentation have been described, from mild
cutaneous manifestations to severe hematological and
cardiac alterations, and other more unusual such as
hepatobiliary involvement (2).
AC, defined as a necro-inflammatory state of the gallbladder in the
absence of cholelithiasis, occurs more
prevalently in critically ill patients, and in those with
septic processes. Although AC is well known, it does
not have an established clinical pattern, but does have
multiple confounding factors that make it a diagnostic
challenge (3), as occurred in the following case.
Clinical case
A 33-year-old, overweight man from Bogotá, with no
known medical history and without SARS-CoV-2 vaccination, consulted for
20 days of oppressive pain in
the epigastrium radiating to the right hypochondrium,
intensity 7/10 and exacerbated by food intake, associated with multiple
emetic episodes of food content,
increasing on the day of admission. With a system review finding of an
eight day dry cough and worsening
dyspnea with small exertion.
Upon physical examination, he presented normotensive, normal
respiratory rate, adequate ambient oxygen
saturation, afebrile, mild tachycardia without cardiopulmonary
alterations, and soft abdomen with sensation of a painful mass in the
right hypochondrium,
but without signs of peritoneal irritation. Paraclinical
tests showed leukocytosis, direct hyperbilirubinemia,
and an alanine aminotransferase-alkaline phosphatase (ALT/ AP) ratio of
0,56 suggestive of cholestasis, but
otherwise normal liver profile. The abdominal ultrasound showed a
partially distended gallbladder, with
thickened walls (9.2 mm), but without endoluminal
defects. General Surgery suspected AC with intermediate risk for
choledocholithiasis and requested a
Magnetic Resonance Cholangiography that showed a
distended, stoneless gallbladder with thickened walls
(7 mm) and a diagnosis of AC and hepatomegaly (Figure 1).
He was taken to surgery to perform a LapC (Laparoscopic
Cholecystectomy) with intraoperative findings
of cholecystitis with thickened walls, perivesicular
fluid, pericholecystic adhesions, biliary sludge, and
congested brown liver.
During the immediate postoperative period, he presented desaturation
and bi-basal rales, for which a chest
X-ray was requested, showing cardiomegaly, widebased pleural
consolidation of the left upper lobe,
suggesting pulmonary infarction, with bilateral basal
pleural effusion, and RT-PCR (Reverse Transcription
polymerase chain reaction) for SARS-CoV-2 positive,
glycated hemoglobin in the range of diabetes, and elevated troponin,
D-dimer and lactate.
Computed Angio-Tomography of the chest corroborated thrombus and wedge
infarction (Figure 2).
Management was given with fluids, full anticoagulation, dexamethasone
after antiparasitic treatment, and
a diagnostic plus evacuatory thoracentesis, which corroborated
transudate without malignancy or tuberculosis.
Gallbladder pathology showed velvety mucosa without
the presence of stones or tumor-like lesions, with inflammation, muscle
hypertrophy, subepithelial histiocytes, Rokitansky sinuses, and serosal
congestion.
He required hospitalization in the general ward with
oxygen by nasal cannula at 2 liters per minute, and due
to adequate evolution, he was discharged after 10 days
with anticoagulation, oxygen therapy and oral hypoglycemic agents.
Additionally, referral for evaluation by Cardiology due to cardiomegaly
in a young patient,
where studies concluded idiopathic heart disease with
reduced ejection fraction. The patient was then referred
to a heart failure clinic, waiting for cardiac transplant.
Figure 1. Magnetic Resonance Cholangiography.
A. Axial view in T2. B. Sagittal view in T2. The arrows show the
gallbladder with thickened walls, perivesicular fl uid,
and no evidence of stones inside.
Figure 2. Computed angiotomography of the chest with contrast,
axial view.
A. The red arrow shows the location of the central opacifi cation
defect, which corresponds to thrombi in the
segmental branch for the superior lingular segment. The blue arrow
indicates a pleural-based wedge infarction in this
same segment.
B. The red arrow shows the location of the central opacifi cation
defect, which corresponds to thrombi in the
posterolateral segmental branch of the right lower lobe. The blue arrow
shows right pleural eff usion, and the yellow
arrow shows cardiomegaly
Discussion
This case report of a patient with AC and COVID-19,
who started with abdominal symptoms prior to respiratory symptoms,
shows how not suspecting SARSCoV-2 in patients with predominant
abdominal symptoms can delay timely management and diagnosis of
its complications, as in this case, a pulmonary thrombotic event.
An increase in gastrointestinal symptoms has been
seen in patients with COVID-19 even before developing pulmonary
manifestations (Table 1) (4-12). This
is a difficult case since the presentation of AC with
SARS-CoV-2 is infrequent, and less so, in a patient
with previous congestive hepatomegaly secondary to
unknown idiopathic heart disease, which, because it is
painful, can confuse the physician when interpreting
suggestive signs of acute hepatobiliary disorder.
AC represents approximately 10% of all cases of acute
cholecystitis and is associated with a high rate of morbi-mortality
(3). Various pathological processes have
been described that may contribute to its generation.
Visceral hypotension and hypoperfusion cause poor
and irregular capillary refill of the gallbladder wall, generating
ischemia, which could explain a possible association with COVID-19 if
it occurs with sepsis (13).
The decrease in contractility of the gallbladder muscle
generates cholestasis, producing accumulation of bile
and increased viscosity, which causes leakage, increased
intracholecystic pressure, distention, and increased
wall tension. This compromises arterial, lymphatic,
and venous flow, leaving it susceptible to infection,
gangrene, or total necrosis. Once AC is established, it allows the
rapid proliferation of microorganisms, predominantly
Escherichia coli, Klebsiella, Bacteroides,
Proteus, Pseudomonas, and Enterococcus faecalis (13,14).
Table 1. Gastrointestinal (GI) symptoms associated with COVID-19.
The exact pathogenesis of AC in COVID-19 is not
clear, but it is known that the intracellular entry of the
virus occurs through interaction with the angiotensinconverting enzyme
2 receptor that is present in various
tissues- lungs, liver, gallbladder and bile ducts. When
SARS-CoV-2 binds, it causes endothelitis which generates
thromboembolism in various organs, including
the gallbladder. (15,16)
Some publications have tried to demonstrate the relationship between AC
and COVID-19. Yin et al. looked
for RT-PCR in the biliary fluid, without detecting it,
ruling out that SARS-CoV-2 is eliminated through bile
and considering that AC is a complication of SARSCoV-2 (17). In
contrast, Balaphas et al. confirmed the
presence of virus, by RT-PCR in the gallbladder wall,
despite the fact that histological analysis did not show
any gallbladder inflammation. The significance of this
finding for the pathogenesis of COVID-19 remains to
be determined (18).
Futagami et al. carried out a bibliographic search of
the published cases of cholestasis related to SARSCoV-2, finding 17
cases (11 men and 6 women); five
of them had no comorbidities. Regarding the onset
of cholecystitis, 15 of them developed simultaneously
with the diagnosis of pneumonia and two of them later. In case number
5, LapC was performed, and after
extubation, he developed respiratory failure, as in the
case of our patient. Additionally, at the time of cholecystitis
diagnosis, laboratory and imaging findings
suggestive of coagulation disorders were confirmed
in seven of the cases. Conversely, regarding the initial
treatment, emergency cholecystectomy was performed
in six patients, and percutaneous drainage in four, of
which two failed and were taken to LapC (16). This
suggests that even in patients with AC due to SARSCoV-2, a TOKIO 2018
classification should be performed and emergency cholecystectomy should
be considered according to guidelines (19,20).
In conclusion COVID-19 can present only with digestive symptoms, or
they can precede the classic respiratory
manifestations. AC is one of the less frequent digestive
manifestations, but it must be considered even though
the pathophysiology in patients with SARS-CoV-2 has
not yet been fully clarified. Differential diagnosis can
be challenging; therefore, a complete history and physical examination
should be systematically performed
to reveal a possible positive case, which could make a
difference in the patient’s outcome.
Patient Consent
Written informed consent was obtained from the patient for publication
of this case report and accompanying images. A copy of the written
consent is available
for review by the editor-in-chief of this journal upon
request.
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Recibido: 28 de
febrero de 2022
Aceptado: 15 de
marzo de 2022
Correspondencia:
Ana María Pérez Murcia
mperez1@fucsalud.edu.co