1396 Viral Acalculous Cholecystitis: A Rare Extrahepatic Manifestation of Hepatitis A

Abstract

INTRODUCTION: Hepatitis A (HAV) is the most common form of acute viral hepatitis worldwide with an incidence of 0.6 reported cases per 100,000 population in the United States. Typical clinical symptoms include nonspecific prodromal symptoms such as fever, malaise, weakness, anorexia, nausea, vomiting and abdominal pain. Atypical features of HAV include recurrent hepatitis, prolonged cholestasis and extrahepatic manifestations. Acalculous cholecystitis (ACC) is an extremely rare extrahepatic manifestation of HAV. We present a unique case of acute hepatitis A presenting as ACC in an adult male with IV drug use. CASE DESCRIPTION/METHODS: A 50 year old male with a history of active IV heroin use and treated hepatitis C presented with nausea and RUQ abdominal pain for 3 days. On admission, laboratory findings were remarkable for AST of 2574 U/L, ALT of 3214 U/L, ALP 321 U/L and total bilirubin of 4.0 mg/dl. On physical examination patient was afebrile and hemodynamically stable with normal bowel sounds, soft abdomen, mild RUQ tenderness to deep palpation and Murphy's sign negative. CT abdomen demonstrated an edematous gallbladder wall with mild pericholecystic fluid and fat stranding, CBD diameter 4.0 mm (Figures 1 and 2). General Surgery believed his overall clinical picture to be due to acalculous cholecystitis and recommended non-operative management. Patients IgM Hepatitis A returned positive, Hepatitis B and C non-reactive. Thus, his findings were attributed to an active hepatitis A viral infection. He was treated conservatively with intravenous fluids and pain control. On discharge the patient remained afebrile, abdominal pain had resolved and liver function tests had normalized. DISCUSSION: Acute Hepatitis A with gallbladder involvement has been described in approximately 50 to 98% of adults. Although the etiology remains unclear, the invasion of the gallbladder by HAV and cell-mediated immunologic response have been proposed in the pathogenesis of HAV induced cholecystitis. The treatment is mainly conservative, as ACC due to HAV is transient and improves with resolution of viremia. Thus, patients do not require surgical interventions, unless they develop severe complications from ACC including gangrene and empyema. Our case demonstrates the importance of having a high clinical suspicion for HAV, especially in patients with known risk factors. Physicians should be cognizant of Hepatitis A and its rare extra hepatic manifestation, such as acalculous cholecystitis in order to avoid unnecessary surgical interventions.