A 40 year-old woman with HIV (CD4 268) on antiretrovirals and pulmonary MAC on treatment presented to the hospital with abdominal pain and diarrhea. She was subsequently admitted to the intensive care unit with sepsis secondary to campylobacter gastroenteritis. Initially, patient’s total bilirubin and alkaline phosphatase were both mildly elevated and ultrasound did not show gallstones, stranding, or gallbladder wall thickening. In the ICU, she was partially stabilized with early goal-directed therapy and imipenem/cilastatin targeted against C. jejuni after no response was noted with ciprofloxacin. She was stepped down to the medical-surgical unit on hospital day 4 with continued abdominal pain, now localized to the right upper quadrant, and fluid-responsive hypotension.
On hospital day 5, in the setting of increased abdominal pain and worsened hypotension, a repeated ultrasound revealed a thickened gallbladder wall of 6 mm. While total bilirubin remained elevated but stable, alkaline phosphatase continued to rise from the low 200s to 945. Gastroenterology and surgery were consulted and she underwent a cholecystotomy and was transferred back to the ICU with a biliary drain in place. Cultures from the drain grew heavy Candida albicans.
After cholecystotomy, she completed a two-week course of fluconazole (stopped for thrombocytopenia with workup negative for other causes) and micafungin and a 14-day course of imipenem/cilastatin for her initial campylobacter gastroenteritis. On hospital day 30, she developed fever, tachycardia, and recurrent diarrhea. She also developed seizures attributed to hypocalcemia, renal failure requiring continuous renal replacement therapy, vancomycin-resistant Enterococcus faecium bacteremia, and respiratory failure requiring intubation. She subsequently expired from overwhelming sepsis on hospital day 37. Autopsy revealed intestinal hemorrhage and acalculous cholecystitis (ACC).
Only eight cases of ACC with C. albicans as the exclusive organism have been reported, and only one previous case in a patient with HIV/AIDS. Candidal ACC has severe clinical sequelae in critically ill patients with an associated mortality of 40 percent. Risk factors include immunosuppression, prolonged ICU stay, and antibiotic therapy – all of which were applicable to this patient. Ultrasound is most accurate for diagnosis with gallbladder wall thickening of 3.5 millimeters or greater making ACC more likely. In critically ill patients with abdominal complaints, a high index of suspicion, early diagnosis, and timely intervention are essential. The mainstay of intervention in ACC is cholecystotomy and has shown improved survival when performed promptly. However, in a retrospective study in patients with severe sepsis and shock, cholecystotomy has been shown to be associated with higher mortality as compared to cholecystectomy. Therefore, discussion with the consulted surgical team should also include cholecystectomy as an option in severely ill patients.
Risk factors for Candida acalculous cholecystitis include immunosuppression, prolonged ICU stay and prior antibiotic therapy. In unstable patients with this fungal infection, cholecystectomy may be the preferred method for treatment as it may improve patient survival.
To cite this abstract:Deere L, Coontz K, Moore A, Fotino A. Approaching the Limits of Acalculous Cholecystitis. Abstract published at Hospital Medicine 2015, March 29-April 1, National Harbor, Md. Abstract 503. Journal of Hospital Medicine. 2015; 10 (suppl 2). https://www.shmabstracts.com/abstract/approaching-the-limits-of-acalculous-cholecystitis/. Accessed July 19, 2019.