Parasitic Infection of the Gallbladder: Cystoisospora belli Infection as a Cause of Chronic Abdominal Pain and Acalculous Cholecystitis

Herein we describe two cases of Cystoisospora belli infection of the gallbladder in patients with chronic abdominal pain and review the published literature to date. C. belli is an intracellular protozoan parasite that typically infects the small bowel of immunocompromised hosts. Little is known of the significance of C. belli infection of the gallbladder at this point as only four cases have been reported as yet, only one of which occurred in an immunocompetent patient. It is often treatable with antibiotics, and the patient's immune status, including HIV testing, should be investigated. Neither of the patients at our institution was found to be immunocompromised, and HIV-1/2 antibody testing was non-reactive in both.

Infectious diseases and the gallbladder

Infections of the gastrointestinal tract can often involve the gallbladder. Infection probably plays a role in the formation of gallstones but is more commonly thought to contribute to acute illness in patients. Acute calculous cholecystitis caused by an impacted gallstone is often complicated by secondary bacterial infection and is a major cause of morbidity and even mortality in patients. A wide variety of organisms can be associated with acute acalculous cholecystitis, a less common but potentially more severe form of acute cholecystitis. This review focuses on infections and their role in the above-mentioned processes involving the gallbladder.

Acute Q fever presenting as antiphospholipid syndrome, pneumonia, and acalculous cholecystitis and masquerading as Mycoplasma pneumoniae and hepatitis C viral infections

We report a case of Q fever-related antiphospholipid syndrome in a patient presenting with acalculous cholecystitis and pneumonia. Serial laboratory tests indicated that the previous serological tests suggesting hepatitis C virus and Mycoplasma pneumoniae infections were false-positives. The patient's fever persisted despite treatment with doxycycline, but disappeared 1 day after initiation of steroid treatment. To avoid incorrect diagnosis and subsequent delays in appropriate treatment of Q fever patients, the possibility that Q fever can masquerade as other infections or as an autoimmune disease should be kept in mind.

Hemorrhagic acalculous cholecystitis: an unusual location of uremic bleeding

Hemorrhagic acalculous cholecystitis is a rare but potentially fatal disease. An increased bleeding tendency is present in both acute and chronic renal failure with impaired platelet function. We herein present a case of hemorrhagic acalculous cholecystitis in a hemodialysis patient who suffered from acute abdomen and upper gastrointestinal bleeding. The pathogenesis may have been associated with ischemia and reperfusion injury, eventually leading to necrosis of the gallbladder wall. Abdominal ultrasound can aid in diagnosis. Biliary colic, jaundice, and melena are the typical symptoms of hemorrhagic cholecystitis, particularly in a patient with unexplained gastrointestinal bleeding.

[Cationic Blue O staining for the cytological detection of Helicobacter pylori]

This investigation was undertaken to study whether cationic blue O staining might be used to improve the cytological diagnosis of H. pylori infection at gastric and extragastric sites. One hundred and sixty-four patients with chronic inflammatory diseases of the stomach and gallbladder were examined with cytological and molecular studies. Impression smears from the gastric mucosa and bile portions A, B, and C were studied. The stain proposed by the authors ensures a high efficiency in detecting H. pylori in different biological materials (gastric biopsy specimens, bile) with the determination of the degree of contamination makes it possible to evaluate the morphological changes in the gastric mucosa and bile epithelium. The detection results of smear H. pylori correlated with those of DNA in this microorganism, by using the polymerase chain reaction. The proposed cytological study may be recommended for both the primary diagnosis of H. pylori infection in patients with diseases of the stomach, duodenum, and gallbladder and the monitoring eradication therapy and its deserves extensive use by cytological laboratories.

Oerskovia turbata and Myroides species: rare isolates from a case of acalculus cholecystitis

Here we report a case of acalculus cholecystitis, which presented with features of obstructive jaundice of one-week duration. The patient underwent cholecystectomy and bile grew a mixed culture of Oerskovia turbata and Myroides spp. Being a rare isolate, characteristic features of the former are described in this report. The patient recovered without any complication.

Dengue fever presenting as acute acalculus cholecystitis

Classically dengue fever presents as fever with myalgia. A patient of dengue fever presented with classical symptoms and signs of acute acalculous cholecystitis. Serology and ultrasound examination identified dengue as the aetiology. Patient was treated successfully by conservative measures.

A case report of dengue virus infection and acalculous cholecystitis in a pregnant returning traveler

Dengue viral infections present a significant risk during pregnancy to both mother and fetus. A young woman at 13 weeks' gestation presented with fever and abdominal pain following a diarrheal illness after returning from Puerto Rico. Over the course of 5 days, she developed nausea, petechiae, severe thrombocytopenia, and acalculous cholecystitis. After a serologic diagnosis of acute infection with dengue virus, she was provided supportive care. An uncomplicated pregnancy led to delivery of a healthy infant at 40 weeks gestation. Travel during pregnancy to dengue-endemic areas poses a risk to both mother and fetus. Pregnancies complicated by dengue infection require close monitoring for potential maternal and fetal complications.

Tight junction proteins in gallbladder epithelium: different expression in acute acalculous and calculous cholecystitis

There is a paucity of information of tight junction (TJ) proteins in gallbladder epithelium, and disturbances in the structure of these proteins may play a role in the pathogenesis of acute acalculous cholecystitis (AAC) and acute calculous cholecystitis (ACC). Using immunohistochemistry, we investigated the expression of TJ proteins claudin-1, -2, -3, and -4, occludin, zonula occludens (ZO-1), and E-cadherin in 9 normal gallbladders, 30 gallbladders with AAC, and 21 gallbladders with ACC. The number of positive epithelial and endothelial cells and the intensity of the immunoreaction were determined. Membrane-bound and cytoplasmic immunoreactivities were separately assessed. We found that TJ proteins were uniformly expressed in normal gallbladder epithelium, with the exception of claudin-2, which was present in less than half of the cells. In AAC, expression of cytoplasmic occludin and claudin-1 were decreased, as compared with normal gallbladder. In ACC, expression of claudin-2 was increased, and expression of claudin-1, -3, and -4, occludin, and ZO-1 were decreased, as compared with normal gallbladder or AAC. We conclude that there are significant differences in expression of TJ proteins in AAC and ACC, supporting the idea that AAC represents a manifestation of systemic inflammatory disease, whereas ACC is a local inflammatory and often infectious disease.

Histopathology of acute acalculous cholecystitis in critically ill patients

AIMS

To illustrate the histopathological features of acute acalculous cholecystitis (AAC) of critically ill patients and to compare them with those of acute calculous cholecystitis (ACC) and normal gallbladders.

METHODS AND RESULTS

We studied 34 gallbladders with AAC and compared them with 28 cases of ACC and 14 normal gallbladders. Histological features were systematically evaluated. Typical features in AAC were bile infiltration, leucocyte margination of blood vessels and lymphatic dilation. Bile infiltration in the gallbladder wall was more common and extended wider and deeper into the muscle layer in AAC compared with ACC. Epithelial degeneration and defects and widespread occurrence of inflammatory cells were typical features in ACC. Necrosis in the muscle layer was also more common and extended wider and deeper in ACC. There were no differences in the occurrence of capillary thromboses, lymphatic follicles or Rokitansky-Aschoff sinuses between the AAC and ACC samples.

CONCLUSIONS

There are characteristic differences in histopathology between AAC and ACC, although due to overlap, none appeared to be specific as such for either condition. These results suggest that AAC is largely a manifestation of systemic critical illness, whereas ACC is a local disease of the gallbladder.

Quantitative cholescintigraphy and bile abnormalities in patients with acalculous biliary pain

Acalculous biliary pain has been related to gallbladder dysfunction that produces a gallbladder emptying defect-a condition which favours the development of lithiasis. It is therefore probable that microlithiasis is present in patients with gallbladder dysfunction. The aims of this study were to measure gallbladder emptying and investigate bile abnormalities in patients with acalculous biliary pain. In 92 consecutive patients, gallbladder emptying was assessed by quantitative cholescintigraphy (abnormal ejection fraction < or =40%). In 64 patients, a microscopic study was performed on duodenal bile, defining abnormality as the presence of cholesterol crystals in any amount and/or calcium bilirubinate granules and/or microspheroliths at a rate of >10 per slide. The ejection fraction was abnormal in 45 patients (49%) (median 25.1%, range 6.8-39.3%) and normal in the remaining 47 cases (median 71.3%, range 41.0-96.1%). Bile was abnormal in 32 of 64 patients (50%), the most frequent finding being calcium bilirubinate granules. In the patients with bile abnormalities, abnormal ejection fraction was more frequent (20 of 32) and the median ejection fraction was lower (30.9%, range 12.0-94.1%) than in the patients with normal bile (16 of 32 with an abnormal ejection fraction; median ejection fraction 50.7%, range 6.8-96.1%). Abnormal bile was frequent (55.5%) in patients with reduced ejection fraction, but was not uncommon in patients with normal ejection fraction (33.3%). Fewer patients showed no alteration (25%). It is concluded that in most patients, acalculous biliary pain coexists with gallbladder dysfunction or abnormal bile, the combination of both alterations being common.

[The role of stomach epithelial cells being immunopositive for NO synthase in the formation of chronic cholecystitis]

The article provides information on 145 patients with chronic acalculous cholecystitis and 62 patients with chronic calculous cholecystitis subjected to a study of the quantitative characteristic of gastric antral epithelial cells immunopositive for NO synthase. The increased number of NO synthase immunopositive gastric epithelial cells at chronic cholecystitis was discovered. Most of them were discovered at the calculous process. The study discovered the relation between the gallbladder inflammatory activity, bile lithogenicity and the number of NO synthase immunopositive gastric epithelial cells. The clinical, biochemical and morphologic analyses showed that the application of Hepabene for treating patients with chronic acalculous cholecystitis produces a clinical and biochemical remission in a shorter term. Bile lithogenicity decreases; the quantitative characteristic of NO synthase immunopositive gastric epithelial cells normalizes. The study results make it possible to recommend Hepabene as a highly efficient drug for treating patients with chronic acalculous cholecystitis.

Conservative management of intrahepatic perforation of the gallbladder secondary to acalculous cholecystitis

Gallbladder (GB) perforation is a rare complication of acute acalculous cholecystitis. This complication mostly manifests as acute free perforation into the peritoneal cavity, subacute pericholecystic abscess, or chronic perforation with cholecystoenteric fistula. Perforation of the GB into the liver is extremely rare, and was reported only in adults, of whom all were treated surgically. The authors present an intrahepatic GB perforation secondary to acute acalculous cholecystitis, and its successful conservative management in a 13-year-old boy.