We present a 61-year-old female from San Luis Potosi, Mexico, with type 2 DM, hypertension, and 2-year history of gallstone disease with no other comorbidities. Her surgical history was not significant. She presented at the Emergency Department of our hospital with a 2-day history of moderate-to-severe colicky RUQ abdominal pain that started an hour after eating a large, fatty meal for breakfast. It radiated to the mid-back and right shoulder and had no alleviating or aggravating factors. Also, she complained of nausea, vomiting, and food intolerance. The patient had previous self-limited episodes of RUQ abdominal pain.
On general examination, she had a poor general status and was diaphoretic and dehydrated with unstable vital signs: a respiratory rate of 20 r/min, a heart rate of 127 bpm, an oxygen saturation of 92%, a blood pressure of 84/52 mmHg, and a body temperature of 38.1 C. The abdominal physical examination revealed tenderness to palpation in the epigastric region with a firm and painful palpable mass in the RUQ abdominal region. Laboratory tests showed an elevated white blood count (WBC) count of 15,670 mcl with 15,400 mcl (98.0%) neutrophils and 235 mcl (1.5%) of lymphocytes, 287,000 mcl platelets, lactate blood levels of 2.3 mmol/l, total bilirubin of 1.09 mg/dl, conjugated bilirubin of 0.45 mg/dl, unconjugated bilirubin of 0.64 mg/dl, creatinine of 0.89 mg/dl, urea of 53.6 mg/dl, prothrombin time of 14.2 seconds, partial thromboplastin time of 35 seconds, and C-reactive protein of 305 mg/L with no other alterations. Blood cultures were obtained prior the start of antibiotics. There was no ultrasound available, but an abdominal computed tomography (CT) scan was performed and showed an enlarged gallbladder with marked wall thickening. Also, a gallstone obstructing the gallbladder neck was shown (Figure 1).
The patient was started with IV antibiotic therapy of ciprofloxacin and metronidazole. Preoperative resuscitation followed by an emergency open cholecystectomy was performed for source control. Surgical exploration revealed omentum and duodenum adherences to the enlarged gallbladder. The gallbladder was also necrotic without perforation. Retrograde gallbladder dissection with subtotal fenestrating cholecystectomy was performed because of the impossibility to identify the common hepatic bile duct, cystic duct, and cystic artery. Intraoperative drainage of the gallbladder was performed, obtaining 60 ml of purulent fluid. Cultures were collected from the content of gallbladder. Saratoga sump drainage was collocated on the liver bed for wound drainage. Because of the risk of bile duct injury along with the procedure and risk of biliary fistula, the patient was taken for an endoscopic retrograde cholangiopancreatography (ERCP), where an endoscopic biliary prosthesis was inserted. All blood and fluid cultures and Gram-stain yield negative. The patient recovered uneventfully without pain and fever and was discharged on the fifth postoperative day.
The gallbladder specimen removed during cholecystectomy was sent for histopathologic examination to the Pathology Department of our hospital. The presence of a gallstone of 5.5 x 3 x 3 cm, a wall thickness of 4-10 mm, and a nodular cheesy-looking lesion of 9 mm were noted. The reported histopathologic diagnosis was AC with areas of caseous necrosis. Routine staining was performed and showed intracellular acid-fast bacilli (AFB). (Figure 2) The gallbladder specimen was sent for molecular testing, where M. tuberculosis was identified by polymerase chain reaction. A diagnosis of AC complicated with gallbladder empyema due to M. tuberculosis was performed and treatment was adjusted. An epidemiological report was sent to our Epidemiology Department and the authorities of the National Secretary of Health for follow-up and starting the antituberculous therapy. They started the shortened primary TB treatment which comprises an intensive therapy with isoniazid, rifampicin, pyrazinamide, and ethambutol for 2 months, followed by 4 months of continuation phase with isoniazid and rifampicin. The patient had completed the intensive phase and currently is in the second month of continuation phase. During follow-up, the patient has not presented any complications due the disease or the treatment.