Brucellosis with acute acalculous cholecystitis.

Abstract

Acute acalculous cholecystitis has been associated, although rarely, with brucellosis. We have recently encountered a 6-year-old previously healthy child with brucellosis who presented with abdominal pain from cholecystitis. Case presentation. A 6-year-old Hispanic boy was admitted to The Ronald McDonald Children’s Hospital of Loyola University Medical Center because of fatigue, loss of appetite and fever for 7 days. The fever ranged from 38.4 to 40.5°C. Abdominal pain developed 3 days before hospitalization. Pain was moderate to severe and was localized to the right upper quadrant. There was no history of emesis, diarrhea or dysuria. He was constipated for 1 week. The patient had visited Mexico for 2 weeks, 4 months before the onset of his fever. On admission the patient appeared ill, but nontoxic. Temperature was 38.1°C, heart rate was 120, respiratory rate was 36 and blood pressure was 101/62 mm Hg. Pertinent findings were confined to the abdomen. The abdomen was soft but was tender in the epigastric and right upper quadrant regions. No rebound tenderness was appreciated. Liver and spleen were not palpable. Abnormal laboratory data on admission included an alanine aminotransferase of 166 IU/l and an aspartate aminotransferase of 176 IU/l. Alkaline phosphatase was 289 IU/l. Complete blood count revealed a white blood cell count of 5300/mm 3 with 18% band forms, 33% segmented neutrophils and 40% lymphocytes. Hemoglobin was 9.3 g/dl, and platelets were 124 000/mm 3. A contrast abdominal computerized tomography scan revealed an enlarged spleen, thickening of the gallbladder wall and fluid surrounding the gallbladder. The fluid also was seen tracking down along the inferior edge of the right lobe of the liver. Acute cholecystitis was suspected, and intravenous antibiotic treatment was begun with ampicillin, gentamicin and metronidazole. On the third hospital day the patient remained clinically stable but was persistently febrile. The spleen became palpable 2 cm below the costal margin. The antibiotic regimen was changed to intravenous cefotaxime when an infectious disease consultant suspected enteric fever. On the fourth hospital day the blood culture grew a Gram-negative rod, which was subsequently identified as Brucella abortus. On the sixth hospital day the antibiotic treatment was changed to trimethoprim-sulfamethoxazole and rifampin. The abdominal pain and fever resolved 4 to 5 days after the above antibiotic regimen was begun. Six weeks later the child was doing well and the antibiotic treatment was discontinued. Discussion. Acute acalculous cholecystitis is a rare complication of brucellosis. There have been no published reports of acute cholecystitis associated with brucellosis in the past 20 years. Very few cases were recorded even during the era in which brucellosis was more prevalent. A MEDLINE search from 1966 to 2000 under the terms of brucellosis and cholecystitis yielded nine reports, and only three of these are of acalculous cholecystitis. The last published case of acalculous cholecystitis associated with brucellosis in the English literature was in 1979. 1 Before 1979 cholecystitis occurring as a complication of brucellosis was reported in 1934 2 and 1947. 3 Berbegal and Rodriguez 4 reported a case in 1986 in the Spanish literature. The pathogenesis of acute cholecystitis associated with brucellosis is unclear. The gallbladder may contain pus harboring the organism. Fluid surrounding the gallbladder may be seen as in our patient. A thickened gallbladder wall without distention is also a possible finding. Medical management of acute cholecystitis is that of treating the Brucella infection. Currently recommended treatment regimens include tetracycline or doxycycline with rifampin. In younger children a regimen of trimethoprim-sulfamethoxazole with rifampin is recommended. Surgical intervention appears to be unnecessary unless perforation of the gallbladder is suspected.