Isolated Gallbladder Tuberculosis Mimicking Chronic Cholecystitis: A Case Report.

Gall bladder tuberculosis: Review of literature

Gastrointestinal tuberculosis is commonly seen in the form of tuberculous peritonitis or involvement of the abdominal lymph nodes. Isolated gallbladder tuberculosis is very rare worldwide, with only 50 cases reported in the literature till 2003. We report a case of a 65 years old male patient who presented with clinical features of chronic calculous cholecystitis. Radiological investigations showed a necrotic mass within fundus with thickened wall of gallbladder along with a calculus suggesting possibility of carcinoma of gallbladder. Laparoscopic cholecystectomy was done and histopathological examination revealed tuberculosis of gallbladder. This case highlights the need to be aware of such unusual presentation of tuberculous in endemic areas and in patients with chronic GIT symptoms. DOI: 10.21276/apalm.1607

Tubercular cholecystitis is an extremely rare form of abdominal tuberculosis. It is a rare entity that often masquerading as chronic cholecystitis. We report a case of a 40-year-old male hospitalized with chronic upper abdominal pain, fever, and cough and subsequently diagnosed as a case of chronic cholecystitis through routine investigations and imaging procedures in a private medical college hospital in Bangladesh. Histopathological examination after cholecystectomy revealed classical features of tuberculosis including granulomas with caseous necrosis and Langhans giant cells. The patient was initiated on anti-tubercular therapy postoperatively and showed excellent recovery. To our knowledge, there are very few reported cases of gallbladder tuberculosis from Bangladesh, particularly from private medical hospital settings. This case underscores the importance of considering tuberculosis in gallbladder pathology in endemic areas. Early recognition and initiation of antitubercular therapy lead to an excellent patient outcomes. Mugda Med Coll J. 2025; 8(1): 69-71

Sir, Tuberculosis of the gall bladder is extremely rare, and hence, not adequately documented.[1] Cholelithiasis is a common association of both tuberculosis and malignancy of the gall bladder. Their clinical presentations also mimic each other.[2] A 58-year-old male patient presented with a year-long complaint of chronic upper abdominal pain along with fever since the last 5 days. There was no prior history of tuberculosis or of contact with such patients. Clinically, he was febrile and the abdomen showed epigastric and right hypochondriac tenderness. Murphy's sign was positive. Hematological examination revealed leucocytosis and neutrophilia. ESR was 67 mm in the first hour. Liver enzymes and chest X-ray were normal. Abdominal ultrasound revealed thickened wall with distended gall bladder and a calculus in the neck of the gall bladder suggestive of chronic calculous cholecystitis. After 3 days of failed conservative treatment, laparotomy through Kocher's incision revealed thickened, distended, and densely adherent gall bladder with omental adhesions. Pus was aspirated from the tense gall bladder. Following adhesiolysis, cholecystectomy was performed by the fundus-first method. Histopathological examination of the specimen revealed features suggestive of acute on chronic cholecystitis with chronic granulomatous reaction and foreign body giant cells. Serum IgG for Mycobacterium tuberculosis was highly positive (H: 1359); whereas, IgM was negative. Sputum was negative for acid-fast bacilli. In view of the positive serological test for tuberculosis, a complete course of antitubercular treatment was administered for 7 months (four drugs—INH, rifampicin, ethambutol, and pyrazinamide—for 2 months and two drugs—INH, rifampicin—for the next 5 months). He remained asymptomatic after 1 year of follow-up. In English literature, >50 cases of tuberculosis of the gall bladder have been reported.[1] Rarity of tubercular involvement of the gall bladder has been attributed to high alkalinity of bile and bile acids inhibiting the growth of tubercle bacillus. It has been suggested that cystic duct obstruction leads to disappearance of bile acids from the gall bladder, which lowers the resistance to this infection. Previous damage to the gall bladder due to gallstones seems to be a prerequisite for the development of tuberculous cholecystitis as almost all reported cases have co-existent gallstones. Literature review revealed only three case reports of tuberculous cholecystitis without associated gall stones or cystic/common bile duct obstruction.[2] Schistosomal cholecystitis is a rare variety of granulomatous infection and must be distinguished from the tuberculous form. In the medical literature, >10 cases of schistosomal cholecystitis are described.[3] Sharara et al.[3] described a case of acute granulomatous schistosomal acalculous cholecystitis. As tuberculous cholecystitis is difficult to diagnose preoperatively, all resected cholecystectomy specimens should be sent for confirmatory histopathological examination, especially in endemic areas where the diagnosis is suspected. In our case, there were dense adhesions around the gall bladder with signs of acute inflammation suggestive of acute on chronic cholecystitis. Moreover, intraoperatively, the gall bladder was found to contain pus and stones at the neck. Surgery was justified in our case since there was co-existent empyema of the gall bladder. A study by Raja et al.[4] showed that the sensitivities of IgG, IgA, and IgM antibodies for tuberculosis are 62, 52, and 11%, respectively, while the specificities are is 100, 97, and 95%, respectively. Kaustova et al.[5] reported that the remarkable sensitivity of the serological tests applied to culture-negative pulmonary and nonpulmonary tuberculosis makes the test a good adjuvant in cases of suspicion of tuberculosis. Although tuberculosis of the gall bladder is a rare entity, we recommend subjecting all resected gall bladder specimens for histopathological examination in endemic areas to rule out tuberculosis.

Laparoscopic cholecystectomy (LC) is now a common method of treating symptomatic gallstones, and it is increasingly being requested by the informed general public. Our aim was to evaluate the role of LC for cholelithiasis and to establish its outcome and the effect of gender on the results. Between September 1994 and June 1999, all patients who underwent LC for cholelithiasis were retrospectively reviewed. They were classified as having acute or chronic cholecystitis (AC or CC). There were 791 patients with CC (633 females, 158 males) and 204 patients with AC (124 females, 80 males). Conversion to open cholecystectomy was needed in 0.76% and 11.8% of the patients with CC and AC, respectively (P<0.00). Four percent of the female patients with AC needed conversion as compared to 23.8% in the males (P<0.00). The low conversion rate in CC limited gender comparison. Median operation time in the patients with CC was 53+/-16 minutes as compared to 74.5+/-35.7 minutes in those with AC (P<0.00). Operation time in the male patients with CC and AC was significantly higher than in the female patients, even after excluding the converted cases (P<0.00). Median postoperative stay for patients with CC was 1.33+/-0.9 days as compared to 1.9+/-1.34 days in patients with AC (P<0.00). No statistical significance in the hospital stay was found between males and females (in CC and AC). There was no mortality in the series. There were three bile duct injuries in the patients with CC. In patients with successful LC, gallbladder perforation occurred in 18% and 31% of CC and AC patients, respectively (P<0.003). Missed stones occurred in 1.4% and 3.3% of the patients with successful LC for CC and AC, respectively. Bile collection, which was treated with open drainage, occurred in four patients with CC and one patient with AC. LC for symptomatic cholelithiasis is safe and feasible; it should be the first choice before resorting to open surgery. In patients with AC as compared to CC, there is an increased conversion rate, longer operation time, longer hospital stay, and higher incidence of gallbladder perforation without an increase in the incidence of bile duct injuries (BDI). Male patients have a longer operation time and higher conversion rate than female patients.

BackgroundVascular invasion is a hallmark of low-grade endometrial stromal sarcoma (LG-ESS), typically presenting a tumor thrombus within the parametrial vessels. However, extension of tumor thrombus into major vessels such as pulmonary artery is extremely rare. This case report presents an unusual manifestation of LG-ESS with intravascular tumor thrombi extending to the pelvic venous and pulmonary artery, highlighting the diagnostic challenges and clinical implications of vascular involvement.Case presentationA 42-year-old female presented with prolonged menstruation. Imaging examination initially suggested multiple uterine fibroids, and hysteroscopic resection of a polypoid lesion revealed stromal hyperplasia, raising suspicion of an endometrial stromal nodule. One year later, the patient developed a pulmonary embolism and imaging showed disease progression. A hysteroscopic biopsy confirmed the diagnosis of LG-ESS. She subsequently underwent total abdominal hysterectomy (TAH) with bilateral salpingo-oophorectomy (BSO) and venous thrombectomy. Histopathological examination revealed LG-ESS with deep myometrial invasion and extensive intravascular tumor thrombus extending into the pelvic veins. The pathological stage was pIIA(FIGO). Postoperative chemotherapy with liposomal doxorubicin was administered, and follow-up pulmonary computed tomography angiography showed resolution of the emboli. No recurrence was noted at the six-month follow-up.ConclusionsThis case highlights the diagnostic complexity of LG-ESS due to its nonspecific clinical presentation and imaging findings, especially in early stages. Rare vascular involvement, including pulmonary artery tumor embolism, poses a risk of misdiagnosis and highlights the importance of thorough histopathological evaluation. Early hysteroscopic intervention, accurate pathological assessment, and individualized adjuvant therapy are critical for optimizing outcomes in patients with LG-ESS exhibiting vascular extension. Informed consent for publication was obtained from the patient.

ObjectiveWe wanted to describe the computed tomography (CT) findings of gallbladder tuberculosis (TB) and to correlate them with pathologic findings.Materials and MethodsThere were seven patients (M:F = 3:4; mean age, 46.3 years; age range, 32 to 78 years) in whom gallbladder TB was eventually diagnosed. All of them underwent cross-sectional imaging with CT, a pathologic examination and a retrospective review. CT imaging evaluation was done in each case, including the findings of a mass versus nodule, wall thickening (uniform or irregular) and the enhancement patterns (homogeneous or heterogeneous).ResultsAll the cases of gallbladder TB revealed the following three different CT findings: micronodular lesion of the gallbladder wall (n = 1), a thickened wall (n = 4) and a gallbladder mass (n = 2). There were three cases of homogeneous enhancement of the lesions, including homogeneous enhancement with nodular lesion, homogeneous uniform thickness enhancement and homogeneous thickness enhancement in one case each, and these cases pathology showed tuberculous granuloma with a little caseating necrosis in one case and tuberculous granuloma with rich fibrous tissue, but little or no evident caseating necrosis in two cases. Four cases of heterogeneous enhancement of the lesions, including heterogeneous uniform-thickness enhancement in two cases, heterogeneous enhancement with a local mass lesion in one case and heterogeneous enhancement with a mass that replaced the gallbladder in one case; in these cases, pathology showed tuberculous granuloma with marked caseation or liquefaction necrosis in three cases and tuberculous granuloma by fibrous and calcifications accompanied by caseating necrosis in one case. Among the seven cases of gallbladder TB, six cases were accompanied by abdominal extra-gallbladder TB, including abdominal lymph node TB in five cases and hepatic TB in four cases.ConclusionGallbladder TB has various CT manifestations, and the enhanced CT findings are well matched with pathological features. An irregularly thickened gallbladder wall or a gallbladder wall mass with multiple-focus necrosis or calcifications accompanied by the typical CT findings of abdominal extra-gallbladder TB should suggest the diagnosis of gallbladder TB.

Gastric cystica profunda (GCP) is a rare disease characterized by multiple cystic lesions in the mucosa and/or submucosal layer. Usually, GCP occurs in stomachs that have previously been operated on. If there is no postoperative pathological results, it is challenging to diagnose GCP based on nonspecific clinical symptoms and imaging findings. This report aimed to provide a comprehensive overview of all cases of GCP reported to date. A comprehensive literature search was conducted for all reported GCP cases between 1972 and 2014. The keywords searched included "gastritis cystica profunda", "submucosal cysts of the stomach", and "heterotopic submucosal gastric glands". One retrospective case from our group was also reported and compared with those from the existing literature. A total of 52 cases were found including 37 (71.2%) men and 15 (28.8%) women (M/F ratio =2.5). The mean age of the patients was 59.9 (range, 39-91) years old. Among the cases, 58.8% (n=30) of lesions were located in the gastric body, 25.5% (n=13) of lesions were located in the fundus, 19.6% (n=9) of lesions were located in the antrum, and 3.9% (n=2) of lesions were located in the cardia, while 1 case was in the prepyloric lesion and 1 case was at the anastomotic site. Of the patients, 52% (n=26) had previously received gastric surgery. The main manifestations of GCP included abdominal pain (n=14, 36.8%) and gastrointestinal bleeding (including hematemesis and melena, n=7, 18.4%). Only 4 of the 52 cases were diagnosed before surgery, and the rest were diagnosed through postoperative histopathologic examination. GCP is difficult to correctly diagnose preoperatively due to its relative rarity and lack of typical clinical symptoms. Histopathological examination should be used for correct diagnosis. Complete surgical removal of the GCP is widely considered as the best treatment option.

Synovitis, acne, pustulosis, hyperostosis, and osteitis (SAPHO) syndrome is a rare disease, which may be underdiagnosed or misdiagnosed because of nonspecific clinical and imaging findings. We present 2 cases of SAPHO syndrome with MRI, bone scintigraphy, and FDG PET/CT findings. In case 1 with early-stage disease, the active osteitis showed osteolytic bone destruction with increased FDG uptake. In case 2 with late-stage disease, the inactive bone lesions presented as osteosclerosis with normal FDG uptake. Familiarity with the FDG PET/CT findings of SAPHO syndrome in different stages may be helpful for correct diagnosis.

Gallbladder tuberculosis is an extremely rare disease that is rarely reported in the literature. Arriving at the correct diagnosis of gallbladder tuberculosis is difficult, and it is usually made by histopathologic examination after cholecystectomy. However, due to the low sensitivity of acid-fast stain and culture result, diagnosing gallbladder tuberculosis is still demanding even after tissue acquisition. To overcome this problem, tuberculosis-polymerase chain reaction (TB-PCR) is performed on the resected specimen, which has high sensitivity and specificity. A 70-year-old female who had previously undergone total gastrectomy for advanced gastric cancer was admitted with right upper quadrant pain. Abdominal ultrasonography and computed tomography revealed acute cholecystitis without gallstones or sludge. She underwent cholecystectomy and the histopathologic finding of the specimen showed chronic active cholecystitis without gallstones or sludge. Because she was suspected to have pulmonary tuberculosis, TB-PCR was also performed on the resected gallbladder. TB-PCR showed positive reaction for Mycobacterium tuberculosis and we could diagnose it as gallbladder tuberculosis. Herein, we present a case of gallbladder tuberculosis diagnosed by TB-PCR from resected gallbladder.

Ophthalmoplegia and vision loss in extrapulmonary tuberculosis with bilateral cavernous sinus involvement

Positron-emission tomography with fluorine-18-fluoro-2-deoxy-D-glucose for gallbladder cancer diagnosis

Tuberculous peritonitis post orchiectomy for testicular tuberculosis; a case report and literature review

Patient: Male, 56Final Diagnosis: Amyloid arthropathy and myopathySymptoms: PolyarthralgiaMedication: —Clinical Procedure: —Specialty: RadiologyObjective:Rare diseaseBackground:Amyloid arthropathy and myopathy are complications of amyloidosis that can be associated with non-specific imaging findings, which may be challenging to interpret. The report is of a case of polyarticular amyloid arthropathy and myopathy in a 56-year-old man with multiple myeloma and includes a description of the radiographic, computed tomography (CT), and magnetic resonance imaging (MRI) findings.Case Report:A 56-year-old man with multiple myeloma presented with chronic polyarticular pain and swelling. Soft tissue thickening of the wrist and knee were found on MRI to be of intermediate T1 weighted imaging (T1WI) and low to intermediate T2 weighted imaging (T2WI) signal intensity. Denervation muscle edema seen in the thenar muscles on the MRI of the right wrist were associated with carpal tunnel syndrome secondary to amyloid deposition. Soft tissue lesions in the periarticular regions of both hip joints were contiguous with subchondral bone lesions. Diffusely scattered myeloma lesions were shown as hyperintense on short tau inversion recovery (STIR) MRI imaging throughout the appendicular and axial skeleton, with vertebral compression fractures. Bilateral iliopsoas involvement with hypertrophy and abnormal surrounding fat reticulated signal intensity was consistent with amyloid myopathy. The patient had a pathological fracture of the right femoral neck and underwent surgical fixation. Histology of the right femoral head confirmed amyloid deposits.Conclusions:Because the clinical presentation and imaging findings of musculoskeletal amyloidosis can be nonspecific, they can result in delay in diagnosis and treatment. Early radiologic identification of polyarticular amyloid arthropathy and myopathy should prompt confirmatory biopsy to confirm the diagnosis.

Primary hepatic angiosarcoma (PHA) is a rare and aggressive malignant liver tumor that is often difficult to diagnose due to its nonspecific clinical presentation and imaging findings. This case series aimed to illustrate the utility of contrast-enhanced ultrasound (CEUS)-guided percutaneous liver biopsy for the definitive diagnosis of unresectable PHA. We report three patients who presented with nonspecific symptoms and hepatic masses. Imaging findings were inconclusive for a definitive diagnosis, and histopathological evaluation was required. All patients underwent CEUS-guided percutaneous liver tumor biopsy. CEUS enabled real-time visualization of viable tumor regions, facilitating accurate needle placement and minimizing sampling from necrotic or hemorrhagic areas.In Case one, multiple punctures were needed to obtain viable tissue due to extensive necrosis. In Cases two and three, CEUS was particularly useful for demarcating poorly defined lesions, resulting in successful tissue sampling with fewer punctures. Biopsies were performed during the post-vascular phase, enhancing diagnostic yield. Histopathological analysis revealed CD31-positive spindle-shaped cells and a high Ki-67 index, confirming the diagnosis of PHA in all cases. All patients died within six months of diagnosis despite chemotherapy, underscoring the poor prognosis and clinical urgency.CEUS-guided percutaneous liver biopsy is a minimally invasive and reliable technique for the diagnosis of PHA, especially in patients who are not candidates for surgery. This approach enables targeted tissue acquisition, potentially improves diagnostic accuracy, and may contribute to the earlier management of this rare malignancy.