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    Home > Active Ingredient News > Infection > Acute acalculous cholecystitis is caused by HIV infection?

    Acute acalculous cholecystitis is caused by HIV infection?

    • Last Update: 2021-11-16
    • Source: Internet
    • Author: User
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    Only for medical professionals to read for reference.
    For suspicious cases at risk of infection, HIV testing should be actively considered as early as possible
    .

    In July 2021, a case report of human immunodeficiency virus (HIV) acute infection with acute acalculous cholecystitis from the team of Professor Hong Jianqing from National Taiwan University Hospital [1], suggesting that acute acalculous cholecystitis may be an acute HIV infection One of the clinical manifestations of the doctors should pay attention to when they encounter such patients in the clinic
    .

     When the case was diagnosed, HIV RNA was >1.
    0×107 copies/ml, and the CD4 cell count was 130/μl
    .

    After treatment with Biktegravir/emtricitabine/propofol tenofovir (B/F/TAF), rapid and sustained virological suppression was achieved
    .

     Case brief introduction General situation: patient, male, 30 years old
    .

    Main complaint: Pain in the upper right abdomen with fever
    .

    Past physical fitness
    .

    Nausea and loose stools for 10 days
    .

    Physical examination: body temperature 38.
    7℃, pulse 105 beats/min, blood pressure 130/94 mmHg, breathing 18 beats/min, oxygen saturation 99%
    .

    The abdomen was slightly swollen, the right upper abdomen was tender, no muscle tension, no rebound pain; no swelling of the liver and spleen
    .

    Laboratory examination: Imaging examination: CT of the abdomen showed gallbladder dilatation, mild gallbladder wall thickening, and no gallstones
    .

    Figure 1: Preliminary diagnosis of the patient’s abdominal CT imaging: acute acalculous cholecystitis Treatment plan: fluoxefol Diagnosis idea: "right upper abdominal tenderness" + "fever" + "gallbladder dilatation, thickening of gallbladder wall" imaging findings can be clear "Acute cholecystitis" diagnosis [2,3]
    .

    Since no gallstones were found on CT examination, the diagnosis was "acute acalculous cholecystitis"
    .

    Table 1 Diagnostic criteria for acute cholecystitis [2,3] Thinking: The inflammatory response in this case was not obvious, the white blood cell count did not increase, or even slightly lower, the proportion of lymphocytes increased while the proportion of neutrophils decreased, suggesting that There may be a virus infection, which requires further observation
    .

    Progression of the disease: On the 4th day of admission, the patient developed maculopapular rash on the abdomen and thighs
    .

     Aspartate aminotransferase (AST) 210 IU/L (↑), ALT 134 IU/L (↑), lactate dehydrogenase (LDH) 712 IU/ml (↑)
    .

     The levels of total bilirubin and direct bilirubin are in the normal range
    .

     At the same time, the platelet count dropped to 75×109/L, and the white blood cell count was 3.
    09×109/L
    .

    Treatment plan: Due to concerns that the patient is allergic to β-lactam antibiotics, he switched to moxifloxacin treatment
    .

    Because the symptoms persisted, the patients were drained percutaneously through the liver and gallbladder, and the symptoms disappeared within 24 hours
    .

    Thinking: Does the patient have other diseases? Acute acalculous cholecystitis is common in critically ill patients, and is associated with trauma, surgery, shock, burns, sepsis, total parenteral nutrition (TPN) and mechanical ventilation, and is caused by cholestasis or gallbladder ischemia [4]
    .

    Acute acalculous cholecystitis occurs in previously healthy patients with no underlying critical illness, which is often caused by infectious factors [4]
    .

    Related pathogens that have been reported include hepatitis A virus (HAV), cytomegalovirus (CMV), Zika virus, new coronavirus (SARS-CoV-2), Epstein-Barr virus (EBV), Cryptosporidium, Sarcosporium Genus, Cyclospora, Leptospira, etc.
    [4]
    .

    Because the patient did not have leukocytosis and elevated bilirubin, the doctor was prompted to check the patient’s immune status and other possible causes of cholecystitis
    .

    Further inspection: HIV antibody and antigen screening test results were positive, plasma HIV RNA>1.
    0×107 copies/ml, CD4 cell count was 130 cells/μL; Western blot results were uncertain (weak P68/66 and P25/24 were present) Belt)
    .

    Serological tests for acute hepatitis A, B, and C were all negative
    .

     Microscopic observation of stool specimens showed negative for Cryptosporidium
    .

     The patient self-reported that he was a man who has sex with men who had unprotected sexual contact about 3 weeks before the onset of symptoms
    .

     Diagnosis: Fiebig IV stage acute HIV infection
    .

    Table 2: Fiebig staging [5] Treatment plan: Start B/F/TAF when B/F/TAF is diagnosed (on the 4th day of hospitalization)
    .

    On the 11th day of B/F/TAF treatment, the symptoms disappeared completely and the patient was discharged
    .

    During the follow-up period after discharge, the patient's AST, ALT, and LDH levels all dropped to the normal range one month after treatment
    .

    Plasma HIV RNA rapidly dropped to 64 copies/ml after B/F/TAF treatment for 6 weeks, and reached the lower detection limit (<20 copies/ml) at 3 and 6 months
    .

     There are few reports of acute acalculous cholecystitis as atypical clinical manifestations in the past
    .

    The pathogenesis of acute acalculous cholecystitis during acute HIV infection is still unclear, but the detection of HIV in the bile specimens of this case may be related to endothelial injury and cholestasis
    .

     After 7 days of treatment in this case, BIC was detected in the patient's blood and bile
    .

    The peak and trough levels of BIC in plasma were 6430 ppb and 3809 ppb, respectively; the BIC concentration in a 24-hour bile sample was 3575 ppb
    .

    This study demonstrated for the first time that high BIC concentrations in bile samples may help control HIV replication in the gallbladder
    .

     Summary Most acute HIV infections have mild symptoms and may have clinical manifestations such as fever, sore throat, nausea and vomiting
    .

    Reported atypical manifestations include acute hepatitis, aseptic meningitis, myocardial pericarditis, gastrointestinal symptoms and so on
    .

    Atypical manifestations can cause delays in diagnosis, or even missed diagnosis, and increase the risk of infection, and urgent clinical attention is needed
    .

     Zhang Lingling et al.
    [6] reported that 62.
    5% of HIV-infected patients first diagnosed with gastrointestinal symptoms in the hospital had a history of out-of-hospital medical treatment, and most of the cases had been in multiple hospitals, mainly primary hospitals, including large general hospitals
    .

    Reviewing the missed diagnosis in the outside hospital, most of them were diagnosed as chronic enteritis, esophagitis, peptic ulcer, intestinal tuberculosis and other diseases
    .

    The reasons for the missed diagnosis include: 1.
    The clinical manifestations of HIV/AIDS are diverse, the complications are not the same, and the clinical manifestations of some cases are atypical; 2.
    Some patients conceal the medical history and lack knowledge of high-risk behaviors, which affects the acceptance of the medical history; 3.
    Diagnosis and treatment by the receiving doctor During the process, he failed to inquire about the medical history and examine the body carefully; 4.
    The doctor who received the doctor did not know enough about the clinical manifestations of AIDS, and was satisfied with the appearance of chronic enteritis, esophagitis, tuberculosis and other AIDS in the digestive tract, and failed to further search for the cause
    .

     In short, this case suggests that acute acalculous cholecystitis may be one of the manifestations of acute HIV infection
    .

    For suspicious cases at risk of infection, HIV testing should be actively considered
    .

    Early diagnosis, bile drainage, and early initiation of antiretroviral therapy may contribute to the early elimination of symptoms
    .

    For more latest literature, guidelines and cutting-edge information in the field of hepatitis, AIDS, and antifungal, please pay attention to "Jizhiyi" reference materials: [1] Liu WD, Cheng CN, Lin YT, et al.
    Acute HIV infection with presentations mimicking acalculous cholecystitis : A case report[J].
    Medicine, 2021, 100(28): e26654.
    [2] Biliary Surgery Group, Chinese Medical Association Surgery Branch, Guidelines for the diagnosis and treatment of acute biliary infections (2021 edition).
    Chinese Journal of Surgery , 2021.
    59(06): p.
    422-429.
    [3]Yokoe M, Hata J, Takada T, et al.
    , Tokyo Guidelines 2018: diagnostic criteria and severity grading of acute cholecystitis (with videos).
    Journal of Hepato -Biliary-Pancreatic Sciences, 2018.
    25(1): p.
    41-54.
    [4]Markaki I, Konsoula A, Markaki L, S et al.
    Acute acalculous cholecystitis due to infectious causes.
    World J Clin Cases.
    2021, 9(23):6674-6685.
    [5]Cohen MS, Gay CL, Busch MP, et al.
    The detection of acute HIV infection[J].
    The Journal of infectious diseases, 2010, 202(Supplement_2): S270-S277 .
    [6],.
    Clinical analysis of AIDS in the first diagnosis of digestive tract symptoms in general hospitals[J].
    Modern Preventive Medicine,2013,40(07):1385-1387.
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