Medical vs Surgical Management of Acute Acalculous Cholecystitis in a Patient with Primary Epstein-Barr Virus Infection

Abstract

Purpose: Case report. Methods: Chart review. Results: An 18 year old Caucasian male presented with a 6 day history of upper quadrant abdominal pain with fevers, nausea and vomiting. Physical exam showed icteric sclera, bilateral cervical lymphadenopathy, upper quadrant tenderness, normal liver size and enlarged spleen. Laboratory investigations revealed elevated bilirubin of 5.7 mg/dl, AST 300 IU/L, ALT 475 IU/L, and ALK-Phos 169 IU/L. Blood counts revealed leukocytosis of 20.26 x 109/L (25.5% atypical lymphoctyes). Ebstein-Barr virus (EBV) serology was positive for IgM antibody against virus capsid antigen. Ultrasound (USG) of abdomen revealed thickened gallbladder wall (1.38 cm), trace pericholecystic fluid, no definite gallstones and non-dilated bile duct at 2.3 mm. He was managed conservatively for acute acalculous cholecystitis (AAC). The next day, his condition did not improve clinically despite mild reduction in liver enzymes. He underwent emergent cholecystectomy and post operative course was uncomplicated with good recovery. Conclusion: AAC caused by primary EBV infection is a rare entity but pathophysiologic pathways are thought to range from cholestatis and inflammatory mediators causing gallbladder inflammation to direct invasion of gallbladder mucosa by virus. USG abdomen usually reveals an inflamed/thickened gall bladder wall (> 3mm), gallbladder distension, biliary sludge and pericholecystic fluid collection. At least 2 of the above USG findings should be present for probable AAC diagnosis. Severe complications like gall bladder microperforations are rare but can be confirmed by presence of extensive fluid collection around the gallbladder and in the lesser pelvis on abdominal CT. Most patients without complications can be followed up with serial USG and managed conservatively. In presence of complications, a low ejection fraction Hepatobiliary Imino-Diacetic Acid (HIDA) scan may help decide in favor of cholecystectomy. Surgical options should be the last step in management of AAC caused by viral infections. Most patients recover with conservative management and serial USG.Figure: Ultrasound abdomen showing thickened gallbladder wall.