Description
● Case Summary:
➣ Patient Profile: A 65-year-old man who had CABG 15 years ago and had ischaemic heart disease and hypertension.
➣ Duration/Complaints presented: Intermittent chills without temperature, two episodes of non-bilious vomiting, and abrupt onset of severe epigastric pain extending to the right upper quadrant.
● Clinical Examination:
➣ Haemodynamically stable (HR 90 bpm, BP 122/75 mmHg, SpO 98% on room air);
➣ Abdomen soft with noticeable discomfort in the right upper quadrant;
➣ Positive Murphy's sign;
➣ Afebrile upon arrival. No hepatosplenomegaly or jaundice.
● Lab Results:
➣ Leukopenia with lymphopenia (lymphocytes ~980/µL);
➣ Elevated CRP of 15 mg/L. Liver enzyme levels significantly increased: ALT 258 U/L, AST 157 U/L, and ALP 708 U/L.
➣ creatinine in serum: 1.2 mg/dL.
● Endoscopic and radiological findings:
➣ Abdominal ultrasound: no sludge or gallstones, gallbladder wall thickening (4.5 mm).
➣ Endoscopic ultrasonography (EUS) results are consistent with acalculous cholecystitis; no stones were seen.
➣ Patchy peripheral ground-glass opacities in both lungs, primarily in the lower lobes, are indicative of COVID-19 on a chest CT scan.
● The differential diagnosis includes:
➣ Acute cholangitis (no CBD dilatation or inconsistent clinical features);
➣ Calculous cholecystitis (inflammatory, ischaemic, or infectious);
➣ Calculous cholecystitis (ruled out by imaging);
➣ Viral-induced hepatobiliary inflammation, including SARS-CoV-2;
➣ Biliary colic or peptic pathology (less likely given findings).
● Diagnostic Verification:
➣ Nasopharyngeal/Oropharyngeal swab rRT-PCR: Positive for SARS-CoV-2. ➣ A correlation between positive PCR and chest CT alterations confirmed the diagnosis of COVID-19 at the same time as acalculous cholecystitis.
● Clinical Significance and Discussion:
➣ Acute cholecystitis is a rare early manifestation of COVID-19. Due to the expression of ACE2 receptors by the biliary epithelium, there is a reasonable explanation for endothelial/microvascular damage to the gallbladder wall or biliary inflammation linked to SARS-CoV-2.
➣ In this instance, a viral or virus-mediated inflammatory aetiology rather than primary calculous illness is supported by the absence of gallstones and the temporal relationship with positive SARS-CoV-2.
➣ When patients exhibit abnormal hepatobiliary symptoms during the pandemic, clinicians should take COVID-19 into consideration, particularly if chest imaging reveals compatible findings.
Protocol
● Therapy & Course:
➣ Supportive care: IV crystalloids, analgesics, liver enzyme and renal function monitoring, antiviral therapy: Favipiravir (1600 mg loading, then 600 mg PO twice daily).
➣ On day two, I experienced a slight temperature and brief dyspnoea, which were treated with supportive care.
➣ By day five, the patient was afebrile, the dyspnoea had gone away, the stomach pain had decreased, and the liver enzymes and inflammatory markers had improved.
➣ Disposition: Asymptomatic at one-week follow-up; discharged in stable condition.
Notes
For more details visit https://pmc.ncbi.nlm.nih.gov/articles/PMC7682978/