A RARE CASE OF CANDIDA ALBICANS ACALCULOUS CHOLECYSTITIS IN A PATIENT BEING TREATED FOR SEVERE CLOSTRIDIUM DIFFICILE

70 year old male admitted for a complicated UTI was placed on piperacillin / tazobactam empirically and subsequently developed abdominal distension and small bowel obstruction. He was admitted to the ICU for fulminant colitis secondary to severe Clostridium Difficile with concern for toxic megacolon. Labs showed a WBC of 34 along with an albumin of 1.8, and a positive c.diff PCR. Abdominal XR showed a dilated ascending colon with a cecal diameter of 6.5cm. Oral and rectal vancomycin along with IV metronidazole started. A 3 day course of IV Immunoglobulins was administered in light of persistent leucocytosis and colonic distension, with eventual improvement of cecal distension and leucocytosis.

Two days into recovery the patient coded. After resuscitation,his WBC uptrended to 100. Bedside RUQ US revealed a thickened and distended gallbladder measuring 5.85cm in diameter, raising concern for Acalculous cholecystitis (ACC). Subsequent percutaneous cholecystostomy performed and bile culture speciated candida albicans. Micafungin was initiated which led to significant clinical improvement.

Discussion:

ACC is an acute necroinflammatory disease of the gallbladder in the absence of cholelithiasis. It accounts for approximately 2-15% of all cases of acute cholecystitis with the incidence being 0.2-0.4% in all critically ill patients. Clinical findings include right upper quadrant pain, fever, leucocytosis and abnormal LFTS. Risk factors relevant to this case include sepsis, shock (septic and cardiogenic), ICU admission, TPN and prolonged fasting. The pathological progression suggested starts with hypo- perfusion and ischemia with gallbladder inflammation, cholestasis and bacterial invasion leading to cholecystitis. Bedside ultrasound has emerged as the first line imaging modality to evaluate suspected AAC with good sensitivity and specificity. Findings include increased wall thickness >3mm, presence of pericholecystic fluid, intramural gas, sludge and gallbladder distention >5cm. Treatment involves the use of antibiotics with cholecystostomy and/or cholecystectomy. Cholecystostomy in this case has many advantages where it can be both diagnostic and therapeutic, providing a microbiologic diagnosis to confirm the diagnosis of AAC and allow targeted antibiotic therapy as well as being overall safer to perform in the critically ill patient. 

In a rapidly deteriorating patient with an already established source of sepsis on appropriate, targeted treatment one must entertain ACC as an alternative source.