S3355 Complicated Cholangitis and the Chaos of COVID-19: A Case Report From the Setting of a Community Hospital Facility

Abstract

INTRODUCTION: We present a case where the evaluation of multiple biliary tract issues were complicated by the patient's underlying cardiac history and may have played a role in the patient's inoculation of the COVID19 virus. CASE DESCRIPTION/METHODS: Patient was an 81 yo Caucasian male with a past medical history of CAD, CABG and mechanical aortic valve on chronic Coumadin therapy, who presented to the ER for intermittent RUQ pain that had been sharp and intermittent for almost a year and loss of appetite. Other pertinent history included a remote history of alcoholism 40 years ago. He was afebrile on admission but was hypotensive and had an initial WBC of 12.01. Initial CT imaging showed numerous gallstones with stones in the CBD as well as pericholecystic fluid and inflammation at the head of the pancreas, thus initial impression was gallstone pancreatitis, acute cholecystitis, and choledocholithiasis. However, given the patient's intital transaminitis, hyperbilirubinemia, leukocytosis, and hypotension, there was also concern for ascending cholangitis. Biliary drain with cholangiogram was performed with biliary fluid cultures growing Serratia sp., α-hemolytic Streptococcus sp, and non-hemolytic Streptococcus sp so IV antibiotics on hospital day 4 were changed to IV ertapenem. Patient's INR was markedly elevated at 7 which prolonged the removal of the biliary drain and given that the stones in the CBD were never actually removed, decision was made on hospital day 8 to replace biliary drain and perform cholangioplasty of distal CBD stricture. As patient's biliary disease stabilized and patient was awaiting rehab placement on the cardiac medical floor, patient's oxygen requirements continued to worsen from nasal cannula to eventual non-rebreather where at that time, COVID19 inflammatory markers were markedly increased and patient was tested positive for the COVID19 virus and went into acute respiratory failure. Patient and his wife made the decision to change patient's code status and he unfortunately passed away while in hospice care on hospital day 14. DISCUSSION: Ascending cholangitis when present on admission should warrant prompt ICU consideration versus a general medical floor. In this case, due to the patient's underlying cardiac history, patient was admitted to the cardiac floor which at the beginning of the COVID19 pandemic was a non-COVID floor with limited PPE, which may have increased the risk of COVID19 exposure to an already immunocompromised patient with a high risk of sepsis.Figure 1.: Initial CT Abd/Pelvis without IV contrast showing cholelithiasis with gallbladder wall thickening and inflammatory pericholecystic fluid and peripancreatic haziness as well as calculi up to 5 mm in CBD consistent with acute cholecystitis, acute pancreatitis, and acute choledocholithiasis.Figure 2.: Organisms seen in biliary fluid culture on hospital day 3. Antibiotic coverage of Meropenem was determined by sensitivities and minimum inhibitory concentration (MIC) as determined by the Infectious Disease department.Figure 3.: Chest X-ray on hospital day 9 showing diffuse scattered perihilar infiltrates as well as a small-moderate left loculated pleural effusion, consistent with COVID19 pneumonia.