Acute acalculous cholecystitis in leptospirosis

Weil's Disease: A Rare Cause of Jaundice

Weil’s disease is a complication of untreated leptospirosis and can be fatal. Awareness of leptospirosis and its hepatic manifestations are limited. We report the case of a 50-year-old man with gastrointestinal symptoms and a cholestatic pattern of liver injury diagnosed with Weil’s disease. The patient showed remarkable improvement after treatment with appropriate antibiotics with normalization of liver function in one month. This case highlights the importance of recognizing leptospirosis and its myriad presentations. 

Gastrointestinal Manifestations of Systemic Diseases in Critically Ill

Systemic disorders can have gastrointestinal (GI) manifestations which are characterized by nausea, vomiting, diarrhea, constipation, abdominal pain, jaundice, and abnormal liver function tests. These gastrointestinal symptoms can be signs of various immunologic, infectious, and endocrine diseases. Gastrointestinal manifestations can be the first signs and symptoms for which the patient can be admitted in a critical care unit. In this article, we will discuss the GI manifestations of various topical diseases, endocrine diseases, and immunological diseases which are the major bulk of patients in intensive care unit (ICU).

How to cite this article: Panigrahy AK, Srinivasan S. Gastrointestinal Manifestations of Systemic Diseases in Critically Ill. Indian J Crit Care Med 2020;24(Suppl 4):S190–S192.

Leptospirosis presenting as acute acalculous cholecystitis

Leptospirosis is the commonest zoonotic infection worldwide but is vastly underreported and extremely heterogeneous in its presentation. Acalculous cholecystitis is an under recognized presentation of acute leptospirosis. In the appropriate clinical context, with a clear exposure history, recognition of this association presents a unifying diagnosis and limits unnecessary surgical interventions.

Atypical manifestations of leptospirosis

Leptospirosis is an illness with a wide spectrum of clinical manifestations and severe illness affects nearly all organ systems. Serious and potentially life-threatening clinical manifestations of acute leptospirosis are caused by both direct tissue invasion by spirochaetes and by the host immune responses. In its severe form, leptospirosis can cause multi-organ dysfunction and death in a matter of days. Therefore it is critical to suspect and recognize the disease early, in order to initiate timely treatment. While the classical presentation of the disease is easily recognized by experienced clinicians practising in endemic regions, rarer manifestations can be easily missed. In this systematic review, we summarize the atypical manifestations reported in literature in patients with confirmed leptospirosis. Awareness of these unusual manifestations would hopefully guide clinicians towards early diagnosis.

[Leptospirosis with necro-haemorrhagic cholecystitis in a Boxer puppy]

A Boxer puppy from the island of Rügen, which was properly vaccinated according to its age, was presented with acute gastrointestinal symptoms. The presumptive diagnosis of leptospirosis with acute renal failure, hepatic damage, and jaundice was confirmed by seroconversion (increased titre to 1 : 800 in a non-vaccine serogroup 4 weeks after disease onset). Cholecystitis was diagnosed based on clinical symptoms and sonographic results. After an initial improvement, the puppy's condition deteriorated and cholecystectomy was performed. Histopathological diagnosis indicated a haemorrhagic necrotizing cholecystitis.

Acalculous cholecystitis: a rare presentation of leptospirosis progressing to Weil's disease

Leptospirosis is a zoonotic infection with higher incidence in tropics. Leptospirosis, is known for its variable manifestations, and is a clinical challenge for physicians in the tropics. Experienced clinicians, at times can mistake leptospirosis for non-medical conditions. A few reports of leptospirosis presenting as acalculous cholecystitis was found in review of literature. We intent to highlight acalculous cholecystitis as a rare but clinically significant presentation of leptospirosis.

Leptospirosis in a Dog with Uveitis and Presumed Cholecystitis

A 7 yr old castrated male Australian shepherd dog was examined for acute change in iris color, lethargy, and anorexia. Uveitis, acute renal failure, and presumed cholecystitis were diagnosed. Based on clinical findings, leptosporosis was suspected, and the dog was treated with antibiotics and supportive care. The dog made a complete recovery, and leptospirosis was confirmed on convalescent titers. Due to the zoonotic potential, leptospirosis should be considered in cases of uveitis, as well as possible cholecystitis.

Acute acalculous cholecystitis: A rare presentation of typhoid fever in adults

Adult typhoidal acute acalculous cholecystitis is rare with only 2 cases having been reported in the English literature. We present the case of a previously healthy 36-y-old female who suffered fever, chills, epigastralgia and progressive jaundice for 3 d, with acute acalculous cholecystitis subsequently diagnosed. In addition to antibiotic therapy with ceftriaxone, open cholecystectomy was performed. However, bile and blood culture both showed Salmonella typhi growth unexpectedly, and ileocolitis was revealed by colonoscopy. Careful tracing of the history of the patient recalled a history of travel to Indonesia. In adults without common risk factors for acalculous cholecystitis, a detailed history including travel to endemic areas and high index of suspicion for typhoidal acute acalculous cholecystitis are important, and appropriate antimicrobial therapy for covering Salmonella typhi should be considered.

Clinical predictors of severe gallbladder complications in acute acalculous cholecystitis

AIM: To evaluate the relationship between clinical information (including age, laboratory data, and sonographic findings) and severe complications, such as gangrene, perforation, or abscess, in patients with acute acalculous cholecystitis (AAC).

METHODS: The medical records of patients hospitalized from January1997 to December 2002 with a diagnosis of acute cholecystitis were retrospectively reviewed to find those with AAC, confirmed at operation or by histologic examination. Data collected included age, sex, white blood cell count, AST, total bilirubin, alkaline phosphatase, bacteriology, mortality, and sonographic findings. The sonographic findings were recorded on a 3-point scale with 1 point each for gallbladder distention, gallbladder wall thickness > 3.5 mm, and sludge. The patients were divided into 2 groups based on the presence (group A) or absence (group B) of severe gallbladder complications, defined as perforation, gangrene, or abscess.

RESULTS: There were 52 cases of AAC, accounting for 3.7% of all cases of acute cholecystitis. Males predominated. Most patients were diagnosed by ultrasonography (48 of 52) or computed tomography (17 of 52). Severe gallbladder complications were present in 27 patients (52%, group A) and absent in 25 (group B). Six patients died with a mortality of 12%. Four of the 6 who died were in group A. Patients in group A were significantly older than those in group B (mean 60.88 y vs. 54.12 y, P = 0.04) and had a significantly higher white blood cell count (mean 15885.19 vs. 9948.40, P = 0.0005). All the 6 patients who died had normal white blood cell counts with an elevated percentage of band forms. The most commonly cultured bacteria in both blood and bile were E. coli and Klebsiella pneumoniae. The cumulative sonographic points did not reliably distinguish between groups A and B, even though group A tended to have more points.

CONCLUSION: Older patients with a high white cell count are more likely to have severe gallbladder complications. In these patients, earlier surgical intervention should be considered if the sonographic findings support the diagnosis of AAC.

Staphylococcal acalculous cholecystitis in a child

Acute acalculous cholecystitis is inflammation of the gallbladder in the absence of gallstones. It usually occurs in critically ill patients and is rare in the pediatric age group. We describe a 12-year-old boy who presented with fever, jaundice, and abdominal pain and was found to have acute acalculous cholecystitis, sacroiliitis, and pelvic osteomyelitis associated with bacteremia as a result of Staphylococcus aureus. Antibiotic therapy without surgical intervention was effective. A high index of suspicion is required to make an early diagnosis and institute appropriate treatment for children with this condition. Although cholecystectomy has been considered the standard therapy, medical treatment alone can be successful.

Leptospirosis

Leptospirosis is a worldwide zoonotic infection with a much greater incidence in tropical regions and has now been identified as one of the emerging infectious diseases. The epidemiology of leptospirosis has been modified by changes in animal husbandry, climate, and human behavior. Resurgent interest in leptospirosis has resulted from large outbreaks that have received significant publicity. The development of simpler, rapid assays for diagnosis has been based largely on the recognition that early initiation of antibiotic therapy is important in acute disease but also on the need for assays which can be used more widely. In this review, the complex taxonomy of leptospires, previously based on serology and recently modified by a genotypic classification, is discussed, and the clinical and epidemiological value of molecular diagnosis and typing is also evaluated.