Case Presentation:
34 year‐old female presented from an Extended Care Facility with tachycardia, hypotension and leukocytosis. Medical history included morbid obesity (BMI 40) with secondary pulmonary hypertension, obesity hypoventilation syndrome, and diabetes mellitus. She had been recently discharged after a prolonged hospitalization due to hypercapnic respiratory failure which required tracheostomy. Her prior hospital course was complicated by gastro‐entero‐cutaneous fistula and chemical peritonitis after percutaneous gastrostomy (PEG) tube placement that had to be removed. Patient was started on total parenteral nutrition (TPN) through a percutaneous inserted central catheter (PICC). At admission blood cultures showed gram negative bacteremia and funguemia. Patient was started on broad spectrum antibiotics. Later, her blood cultures were reported to be positive for Klebsiella pneumonia and Candida glabrata. She was continued on gram negative coverage and anidulafungin. PICC line was removed. The tip of the catheter culture was positive for Candida glabrata (>100 CFU). Patient was bacteremic and funguemic for 4 days until blood cultures cleared. Transesophageal echocardiogram was negative for endocarditis. Other possible sources of infection were ruled out. Patient improved clinically and remained afebrile for three days until she started to complain of right upper quadrant pain, fever and tachycardia. Liver enzymes were noted to be elevated (AST 466 IU/L and ALT 277 IU/L) along with elevated alkaline phosphatase (734 IU/L) and direct hyperbilirubinemia (2.4 mg/dL). Ascending cholangitis was suspected. Patient became febrile and tachycardic. ERCP was done which did not show stenosis in the biliary tree. Abdominal ultrasound and HIDA scan showed acalculous cholecystitis. Patient was continued on anidulafungin and broad spectrum antibiotics. A percutaneous cholecystostomy drain was inserted by interventional radiology with significant clinical improvement. Bile cultures grew Candida glabrata (Figure 1). Patient was discharged in stable condition 4 days after drain placement. Blood cultures remained negative. Treatment was continued for 4 weeks in total when anidulafungin was stopped and the drain removed.
Discussion:
Acalculous cholecystitis is a life‐threatening complication in critically ill patients (few cases series reported in the literature). Candida albicans and Candida glabrata are the most frequent pathogens. The risk factors include major surgery, immunosuppression, antibiotic therapy, parenteral nutrition, complex fistulae, disseminated malignancy and prolonged intensive care unit stay. Although rare, acalculous Candida cholecystitis is associated with very high morbidity and a mortality rate of 40%. A primary source needs to be searched for and treated. In this case, the primary source was most likely a line infection in the setting of a patient on TPN. Early diagnosis necessitates an aggressive approach to the critically ill patient with abdominal complaints.
Conclusions:
Acalculous Candida cholecystitis is a rare and life‐threatening disease. A high index of suspicion in a critically ill patient with multiple risk factors, proper antifungal therapy and prompt drainage were the key elements for a favorable outcome in this case.
