Cesar Davila-Chapa, MD
Resident Physician
LSU Health Shreveport
Shreveport, Louisiana
Disclosure information not submitted.
Rajkamal Hansra, MD
Doctor
Louisiana State University Health Sciences Center
Shreveport, Louisiana, United States
Disclosure information not submitted.
Nasim Motayar, MD
Assistant Professor of Clinical Medicine
Louisiana State University Health Sciences Center
Shreveport, Louisiana
Disclosure information not submitted.
Title: A Case of Silent Secondary Fungal Peritonitis in the Intensive Care Unit
Case Report Body:
Introduction: Perforated Gallbladder is a rare progression of acute cholecystitis that carries a 100% mortality rate if undiagnosed. Common symptoms include fevers, generalized abdominal tenderness, and right upper quadrant pain. However, a subset of patients remains asymptomatic leading to a delayed diagnosis. To increase awareness to this latter group we report a case of a patient with asymptomatic gallbladder perforation.
Description: A 74-year-old female with a history of diabetes and cirrhosis was transferred to the ICU for management of acute hypoxemic respiratory failure. CT abdomen from an outside facility had shown dilated gallbladder with stones and a cirrhotic liver which was not explored on admission due to normal hepatic enzymes and lack of symptoms. Throughout her ICU stay the patient developed subtle signs of end organ dysfunction, specifically acute kidney injury despite normal lactate and hemodynamic stability. Patient complained of a transient episode of mild abdominal pain that resolved. Blood cultures grew yeast, prompting further evaluation for source and treatment with antifungals. Abdominal ultrasound was unable to visualize the gallbladder and showed ascites. A diagnostic paracentesis was performed to look for source of fungemia. Ascitic fluid was greenish brown in color, analysis revealed white blood cell count of 4110, 93% segmented neutrophils, SAAG score of 1.3, and fluid bilirubin of 12.8. This was suggestive of secondary bacterial peritonitis, and surgery was emergently consulted for evaluation. CT scan revealed signs of abscess and gallbladder rupture. Exploratory laparotomy, evacuation of abdominal bile, and cholecystectomy was performed. Peritoneal fluid cultures also had fungal growth. Antifungals were continued with successful clearance of Candida topicals from her blood.
Conclusion: Atypical presentation of perforated gallbladder is a diagnostic challenge. Risk factors associated with silent presentation of perforated viscus include diabetes and cirrhosis. In this subset of patients, clinicians should consider follow up imaging despite normal laboratory values or lack of clinical symptoms. There should be a lower threshold for CT abdomen, the diagnostic modality of choice, and early surgical intervention is vital.