Acute Acalculous Cholecystitis Associated with Q Fever: Report of Seven Cases and Review of the Literature

Q fever is a worldwide-occurring zoonosis caused by Coxiella burnetii. There are various clinical manifestations of acute Q fever, of which acute cholecystitis is a very rare clinical presentation. This study reports seven cases of acute cholecystitis associated with Coxiella burnetii and reviews two other cases from the literature. All patients were admitted to hospital for fever and abdominal pain in the right upper quadrant. Abdominal echography showed a distended gallbladder with biliary sludge without concrements in eight cases and with a single stone in one case. Diagnosis was made by specific serological investigation (microimmunofluorescence assay) for Coxiella burnetii. All nine patients were cured, six after laparoscopic cholecystectomy and three with antibiotics only. Histological examination of the gallbladders showed inflammation in five cases, although Coxiella burnetii was not detected by immunohistochemistry. The results show that laboratory investigations in patients admitted to hospital for symptoms consistent with acute acalculous cholecystitis should include a systematic search for Coxiella burnetii. Electronic Publication     

Serological and molecular study of Leptospira in pediatric patients at a tertiary care centre of northern India

Leptospirosis is considered as one of the most neglected zoonotic tropical diseases. Animals and humans acquire this infection through direct contact with contaminated urine or body fluids of infected animals. This prospective study was undertaken to know the proportion of leptospirosis in pediatric patients presented with acute febrile illness at the Post Graduate Department of Microbiology, King George's Medical University, Lucknow, Uttar Pradesh. Blood samples were collected over a period of one year from January to December 2018 from 70 pediatric patients aged up to 0–12 years presented with febrile illness for 3–14 days. Out of the 70 samples, 7 (10%) samples were found positive by IgM ELISA, 4 (5.7%) samples were positive by MAT and 3(4.3%) were found positive by PCR. Risk factors such as contact with infected animals and contaminated environment were highly associated with seropositivity of leptospirosis. Clinical symptoms such as fever, chills, myalgia, headache, abdominal pain and cough were significantly associated (p < 0.05) with the seropositivity of leptospirosis.     

A rare case of leptospirosis with isolated lung involvement

Leptospirosis is a zoonosis caused by a pathogenic spirochete “leptospira interrogans.” Severe form of leprospira infection is usually associated with jaundice and renal involvement, leading to major hemorrhagic complications. Lung involvement can vary from subtle clinical features to deadly pulmonary hemorrhage and acute respiratory distress syndrome (ARDS). We recently managed a case of leptospirosis with isolated lung involvement as alveolar hemorrhage and ARDS. Our patient had acute febrile illness with respiratory symptoms associated with radiological picture of pulmonary hemorrhage. Patient was managed with noninvasive ventilation with high flow oxygen, antibiotic and pulse steroids therapy. In conclusion, leptospirosis can present with predominant pulmonary involvement, instead of the classical triad of Weil disease. High index of suspicion should be kept in acute febrile illness patients with respiratory symptoms and alveolar hemorrhage. Early diagnosis and management with oxygenation, antibiotics and immunosuppresents can prevent complications and mortality.     

Acute Cholecystitis in Patients with Scrub Typhus

Acute cholecystitis is a rare complication of scrub typhus. Although a few such cases have been reported in patients with scrub typhus, the clinical course is not well described. Of 12 patients, acute cholecystitis developed in 66.7% (8/12) of patients older than 60 yr. The scrub typhus group with acute cholecystitis had marginal significant longer hospital stay and higher cost than the group without cholecystitis according to propensity score matching. Scrub typhus should be kept in mind as a rare etiology of acute cholecystitis in endemic areas because the typical signs of scrub typhus such as skin rash and eschar can present after the abdominal pain.     

A case of hemorrhagic gallbladder paraganglioma causing acute cholecystitis.

Gallbladder paraganglioma is a very rare tumor and so far only a few cases have been reported. Most of these were asymptomatic and were found incidentally during operation. Recently, we experienced a gallbladder paraganglioma that gave rise to hemorrhage, which in turn caused acute cholecystitis. Our case involved a 45 year-old female patient complaining of an intermittent right upper abdominal pain. After a preoperative evaluation, cholecystectomy and lymphadenectomy were performed under the impression of gallbladder cancer with acute cholecystitis. Postoperative pathologic examination revealed a hemorrhagic gallbladder paraganglioma accompanied by acute cholecystitis. Immunohistochemical staining of the chief cells for neuron specific enolase, chromogranin and synaptophysin were positive. Sustentacular cells also stained positively for S100 protein.     

Hanta hemorrhagic fever with renal syndrome: a case report and review.

Hantavirus infection is seldom reported in Taiwan. The spectrum of clinical severity ranges from mild to severe and may cover Hantavirus pulmonary syndrome and hemorrhagic fever with renal syndrome (HFRS). We report a case of HFRS in a 24-year-old soldier presenting with fever, chills, abdominal pain and generalized myalgia. His clinical course progressed through febrile, hypotensive, oliguria and polyuria phases. Hantavirus infection was proven by serology at the second hospital week. The patient was successfully treated with supportive management. Clinicians should be alert to the possibility of HFRS when examining patients with symptoms of fever, renal function impairment, hemorrhagic tendency and with rural exposure in Taiwan.     

Clinical characteristics and follow-up of patients with AIDS and acute abdominal pain

Abdominal symptoms frequently affect patients with AIDS. Acute abdominal pain is a diagnostic challenge that may require elective or urgent surgical treatment, although information about the latter is scarce. In this study we analyzed the clinical findings and follow-up of acute abdominal pain complicating patients with AIDS. In a two-year period, we collected several variables from patients with AIDS and acute abdominal pain: demographic, laboratory, clinical symptoms, initial diagnosis, surgical findings, post-surgical and histopathological diagnosis and post-surgical complications. From 232 hospitalized patients, 34 had acute abdominal pain: 32 male and 2 women (median age = 32 years; range 26 to 58 years). Twenty-two patients required surgical treatment. Eight patients had a post-surgical complication; in five of them, six surgical re-interventions were performed. Three deaths occurred in the 30-day period after surgery. Survival for patients conservatively treated was 4 months (1 to 17 months), vs. 6.5 months (1 to 20 months) in the surgically treated group. Physicians should be aware about the several diagnostic possibilities of acute abdominal pain complicating patients with AIDS. Delay of surgery in these patients may be lethal. Surgery has an important role in the integral treatment of patients with AIDS.     

Early diagnosis of leptospirosis by immunoglobulin M immunoblot testing

There is an urgent need for the development of serodiagnostic approaches with improved sensitivity for patients with acute leptospirosis. Immunoblots were performed on 188 sera collected from 74 patients with laboratory-confirmed early leptospiral infection to detect immunoglobulin M (IgM) antibodies to antigens pooled from 10 leptospiral strains prevalent in Thailand. Sera from patients with other febrile diseases served as controls. IgM reactivity to seven distinct antigens, with apparent molecular masses of 14 to 18, 19 to 23, 24 to 30, 32, 35/36, 37, and 41/42 kDa, was observed. The low-molecular-mass 14- to 18-kDa band was the most frequently detected antigen, being recognized in sera from 82.4% of patients during the first 3 days after the onset of symptoms. We evaluated the accuracy of the IgM immunoblot (IgM-IB) test by using reactivity to the 14- to 18-kDa band and/or at least two bands among the 19- to 23-, 24- to 30-, 32-, 35/36-, 37-, and 41/42-kDa antigens as the diagnostic criterion. The sensitivities of the IgM-IB test and the microscopic agglutination test (MAT) were 88.2% and 2.0%, respectively, with sera from patients 1 to 3 days after the onset of symptoms. In contrast, the IgM-IB test was positive with only 2/48 (4.2%) sera from patients with other febrile illnesses. The high sensitivity and specificity of the IgM-IB test for acute leptospirosis would provide greatly improved diagnostic accuracy for identification of patients who would benefit from early antibiotic intervention. In addition, the antigens identified by the IgM-IB test may serve as components of a rapid, accurate, point-of-care diagnostic test for early leptospirosis.     

Spectrum of Infections in Acute Febrile Illness in Central India

Introduction: Infectious agent when enters in the host results in febrile illness. This may lead to increase in morbidity or even mortality in undiagnosed/untreated cases. There are many aetiological agents which lead to acute febrile illness. Among these aetiological agents, important is bacterial or viral aetiology. Objective: The objective of this study is: (i) To know the aetiological agents responsible for acute undifferentiated febrile illness (AUFI) by serological test or by bacterial culture and (ii) To know the clinical profile of AUFI. Methodology: A total of 270 patients were enroled in the study with a history of AUFI admitted in medicine and paediatric department from January 2015 to November 2016 of tertiary care hospital of central India. Blood sample was collected for blood culture, clot culture and serological tests for immunochromatographic tests (ICTs) and ICT-positive results were confirmed by respective enzyme-linked immunosorbent assay (ELISA). All negative serum samples by immunochromatography were retested for disease-specific ELISA as scrub typhus, dengue and leptospirosis. Results: Out of 270 patients, 127 (47%) were of scrub typhus, 33 (12%) were malaria cases, 47 (17.40%) were dengue, 12 (4%) were enteric fever, 5 (2%) were leptospirosis, undiagnosed were 18 (6.66%) and other infections (viz viral, urinary tract infection, upper and lower respiratory tract infection and acute gastroenteritis) accounts for 28 (10.37%) cases. We have also noticed that there was co-infection of scrub typhus and dengue, leptospirosis and scrub typhus. Conclusion: It is important to know the cause and clinical profile of AUFIs for their proper management also it will help to prevent morbidity and mortality in AUFI cases.     

Surveillance active de la leptospirose humaine en milieu hospitalier au Cambodge

Leptospirosis has been so far poorly described in Cambodia and is probably underdiagnosed in the current local medical practices, although conditions to its active circulation exist in this country. Between June 2006 and July 2007, 612 patients admitted to Takeo hospital and Calmette hospital in Phnom Penh presenting clinical symptoms compatible with leptospirosis, were recruited for biological investigation of leptospirosis markers: PCR detection of bacterial DNA and serology using an Elisa-IgM test and the micro-agglutination reference test (MAT). One hundred eighty-three patients (29.9%) were found to be carrying at least one biological marker of leptospirosis, 88 (14.4%) showed an acute infection profile, evidenced by a positive PCR. The proportion of patients with an immune phase profile (15.5%) suggests former contacts with Leptospira and possible infections with little or no symptoms. Thirteen serogroups of Leptospira have been identified, with predominance of Panama, Pyrogenes and Australia, illustrating a probable wide range of animal reservoir hosts. Serogroup Icterohaemorrhagiae was found in only 4% of cases, contrasting with usual features of human leptospirosis. No significant link between infection and sex, age or occupation could be established, suggesting a permanent exposure of the population in its daily life rather than the existence of risk groups. This study, the largest conducted to date on leptospirosis in Cambodia, confirms the importance of this zoonotic disease, that must be considered a real public health issue in this country.     

Immune-complex-like disease in the course of Enterobacter cloacae sepsis due to cholelithic cholecystitis preceded by influenza vaccination

This case report describes a 52-y-old male patient who, one week after influenza vaccination, presented with abdominal symptoms: pain in the right epigastrium followed by liver dysfunction and pyrexia, as well renal failure, muscles pain and consciousness disorders. Immune-complex-like disease and Enterobacter cloacae sepsis due to cholelithic cholecystitis were diagnosed. In this case, a correlation between vaccination and immune complex-like-disease was suspected based on the onset of symptoms a few days after vaccination and clinical improvement after plasmapheresis. The etiopathogenesis of immune-complex-like disease in this case possibly could relate to the similarity of the vaccine antigens and E. cloacae antigens as well a genetic predisposition.     

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.     

Leptospiral Infections in Humans

Leptospirosis is a globally widespread spirochetal infection spread from animals to humans. Infections are common in settings of endemicity, primarily in tropical regions of the world. Leptospirosis is typically a self-limited febrile illness but may progress to potentially fatal multiorgan system failure. Patients often present with a nonspecific acute febrile illness that is clinically difficult to distinguish from other similarly presenting infections endemic to tropical regions, including dengue fever, influenza, and malaria. A high index of suspicion is essential to early identification of patients who may benefit from antimicrobial therapy. Diagnostic testing is key to both recognition of early infection and outbreak investigation, typically in the setting of water exposure after heavy rainfall and flooding. This review focuses on the epidemiology, clinical manifestations, and laboratory diagnosis of leptospirosis, including nucleic acid amplification tests, culture, direct detection, and serological approaches.     

Leptospirosis in children of Libreville: difficult diagnosis, apropos of 1 case

Leptospirosis is a widespread zoonosis, which is diagnosed less frequently in children than might be expected from the level of exposure to hazards, especially in tropical areas. A 15 1/2-year-old Gabonese boy was admitted following five days of fever, headache, myalgia, abdominal pain, diarrhea, intestinal bleeding, jaundice and conjunctival suffusion. Laboratory data showed abnormal liver and renal function tests, and diagnosis of Plasmodium falciparum malaria was confirmed by thin blood smear. The patient did not clinically improve despite antimalarial treatment and then leptospirosis was suspected. Serologic tests were performed and leptospirosis was later confirmed. Antibiotic treatment (cefuroxim) was given. The outcome was good, liver and renal tests returned to normal in a few days. In tropical area, leptospirosis should be considered in children who are diagnosed with either an unexplained fever, a pseudo-influenza syndrome, or jaundice with hepatorenal involvement and gastrointestinal bleeding.     

Pancreatitis and cholecystitis in primary acute symptomatic Epstein-Barr virus infection – Systematic review of the literature

Acute pancreatitis and acalculous cholecystitis have been occasionally reported in primary acute symptomatic Epstein-Barr virus infection. We completed a review of the literature and retained 48 scientific reports published between 1966 and 2016 for the final analysis. Acute pancreatitis was recognized in 14 and acalculous cholecystitis in 37 patients with primary acute symptomatic Epstein-Barr virus infection. In all patients, the features of acute pancreatitis or acalculous cholecystitis concurrently developed with those of primary acute symptomatic Epstein-Barr virus infection. Acute pancreatitis and acalculous cholecystitis resolved following a hospital stay of 25 days or less. Acalculous cholecystitis was associated with Gilbert-Meulengracht syndrome in two cases. In conclusion, this thorough analysis indicates that acute pancreatitis and acalculous cholecystitis are unusual but plausible complications of primary acute symptomatic Epstein-Barr virus infection. Pancreatitis and cholecystitis deserve consideration in cases with severe abdominal pain. These complications are usually rather mild and resolve spontaneously without sequelae.     

Recent observations on leptospirosis in Northern Ireland and their bearing on current diagnostic methods

An investigation was undertaken to assess the present importance of leptospiral infections in Northern Ireland, and in particular to look for evidence of infection by leptospiral serotypes other than L. icterohaemorrhagiae and L. canicola.Blood samples from 335 patients, sent to the laboratory for a variety of tests, were examined. After initial screening with five groups of pooled antigens, tests for leptospiral agglutinins were completed with formolized antigens prepared from 13 different serotypes. In seven patients a diagnosis of acute leptospirosis was made while nine others showed serological evidence of previous leptospiral infection. Attempts to isolate leptospirae by culture from 29 blood samples were unsuccessful.The serological results indicate that two additional leptospiral serotypes, namely L. ballum and L. bratislava, are causing human infection in Northern Ireland, and presumably also in other parts of the British Isles. Some clinical and epidemiological features associated with different types of leptospiral infection are described. It is stressed that leptospirosis is essentially a febrile illness, that meningeal symptoms are common, and that (contrary to popular belief) jaundice is by no means a constant occurrence.The implications of these findings are discussed, with special reference to the diagnosis of leptospiral infections. Laboratory diagnostic procedures are briefly reviewed, and the possible deficiencies of the agglutination test commonly used in Britain are pointed out. Some suggestions are made concerning both clinical and laboratory aspects of diagnosis, and the need for a reliable screening test for all forms of leptospiral infection is emphasized.     

Indigestion or infection? Unusual presentations of malaria in general practice.

Two cases of vivax malaria which presented atypically as abdominal pain are described. They highlight the need to consider malaria in the differential diagnosis of any acute febrile illness in a patient returning from an endemic malarial area.     

Xanthogranulomatous cholecystitis: clinicopathological study of 13 cases.

In a retrospective three year study 13 cases of xanthogranulomatous cholecystitis (XGC) (seven female, six male) were found in 724 gallbladders (1.8%), an estimated incidence of 1.7 cases per 100,000 population per annum. Symptoms often began with an episode of acute cholecystitis and persisted for up to five years. There was extension of xanthogranulomatous tissue into adjacent organs in nine cases. Three patients had fistulae from the gallbladder, one to skin, and two to the duodenum; this is the first report of this complication in XGC. In two patients XGC sufficiently resembled carcinoma for the surgeon to request intraoperative frozen section diagnosis. There was a high rate of postoperative infective complication, with one subphrenic abscess and three wound infections (one fatal), two in patients with fistulae.     

Acute Pancreatitis Induced by Methimazole Treatment in a 51-Year-Old Korean Man: A Case Report

Methimazole (MMI)-induced acute pancreatitis is very rare but severe adverse reaction. A 51-yr-old male developed a high fever, chills, and abdominal pain, two weeks after commencement on MMI for the treatment of Graves'' disease. There was no evidence of agranulocytosis, and fever subsided soon after stopping MMI treatment. However, 5 hr after taking an additional dose of MMI, abdominal pain and fever developed again. His symptoms, biochemical, and imaging studies were compatible with acute pancreatitis. After withdrawal of MMI, he showed clinical improvement. This is the first case of MMI-induced acute pancreatitis in Korea. Clinicians should be aware of the rare but possible MMI-induced pancreatitis in patients complaining of fever and abdominal pain.

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Unusual clinical manifestations of leptospirosis

Leptospirosis has protean clinical manifestations. The classical presentation of the disease is an acute biphasic febrile illness with or without jaundice. Unusual clinical manifestations may result from involvement of pulmonary, cardiovascular, neural, gastrointestinal, ocular and other systems. Immunological phenomena secondary to antigenic mimicry may also be an important component of many clinical features and may be responsible for reactive arthritis. Leptospirosis in early pregnancy may lead to fetal loss. There are a few reports of leptospirosis in HIV-infected individuals but no generalisation can be made due to paucity of data. It is important to bear in mind that leptospiral illness may be a significant component in cases of dual infections or in simultaneous infections with more than two pathogens.