Acute Acalculous Cholecystitis with Empyema due to Salmonellosis

Case Reports in Gastrointestinal Medicine
03 May, 2019 ,

A previously healthy patient developed acalculous cholecystitis and empyema due to infection by Salmonella. He underwent explorative laparotomy in emergency setting, and cholecystectomy was performed due to his toxic clinical condition. Empyema of gallbladder was revealed and cultures were collected. A combination of antibiotics (ciprofloxacin and metronidazole) was set, and the patient was discharged 8 days after the surgical operation in good condition. 

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A 32-year-old previously healthy male was admitted to our hospital with generalized abdominal pain, diarrhea, nausea, vomiting, and fever up to 39°. During assessment he was febrile without chills at 39°, BP at 135/70, pulse rate of 95 bpm, and respiratory rate at 20 breaths per minute. By his physical examination the abdomen was mildly tender to palpation with guarding in his epigastric and umbilical region.

Laboratory tests disclosed a white cell count of 14.4x1000/μL with 92% neutrophils, 3.5% lymphocytes, normal red blood cell count (5x10∧6/μL), haemoglobin (14.5g/dL), and platelets (160x1000/μL). The biochemical studies including liver, renal, and coagulation profile were normal. There were a mild hyponatremia and hypokalemia and CRP was 8.56. Cultures were obtained from blood, stool samples were obtained, and ceftriaxone and metronidazole were empirically administered.

Furthermore, no abnormalities were detected on chest and abdomen X-ray whereas an urgent abdominal ultrasound revealed thickening of the gallbladder wall, gallbladder contraction, and a minor pericholecystic fluid collection, without dilation of common bile duct or intrahepatic biliary system. In view of the clinical and ultrasonographical findings, the patient was diagnosed with acute acalculous cholecystitis and he was hospitalized initially for fluids, antibiotics, and observation.

After 36 hours of hospitalization, the patient was still febrile with fever up to 39°; however, there were obvious symptoms of toxicity. His vital points were 120bpm, BP 110/60, and 24 breaths/minute. By physical examination, the whole abdomen was contracted, with rebounding pain in the upper right upper quadrant region and Murphy’s sign. Laboratory studies revealed precipitation of white blood cell count at 3.8x1000/μL with 67.4% neutrophils and 18.9% lymphocytes.

Red blood cells were at 4.2x10∧6/μL, haemoglobin at 12.6g/dL, and platelets at 125.5x1000/μL. His abdominal ultrasound showed pericholecystic fluid collection, large free fluid at Douglas’s pouch, and right paracolic gutter. The CT-scan of the abdomen showed thickening of the gallbladder wall, pericholecystic fluid collection, without biliary dilation, a large amount of free fluid at infrahepatic area and mostly in the pelvis, and right and left parabolic gutters.

The patient underwent exploratory laparotomy in emergency setting, and the findings were a swollen oedematous, acalculous gallbladder with empyema, and an amount of free fluid in the peritoneal cavity. After the check of the whole abdomen, he underwent cholecystectomy. Cultures were collected from the content of gallbladder and free fluid.

At the same time the first cultures isolated Salmonella at stool and in the sequel; according to antimicrobial susceptibility test, he was given ciprofloxacin and metronidazole. Pathological findings confirmed the severity of cholecystitis. The culture from content of gallbladder isolated alsoSalmonella. He was discharged with oral antibiotics after 8 days of his admission.