Rare or Overlooked Cases of Acute Acalculous Cholecystitis in Young Patients with Central Nervous System Lesion

Abstract

This case series presents two cases of acute acalculous cholecystitis (AAC)-a rare condition-in young women with central nervous system (CNS) lesions. Both patients had significant neurologic deficits and no well-known risk factors or presence of comorbidities (such as diabetes or a history of cardiovascular or cerebrovascular disease). Early diagnosis is important in cases of AAC owing to its high mortality rate; however, due to neurological deficits in our cases, accurate medical and physical examinations were limited, thereby leading to a delay in the diagnosis. The first case was of a 33-year-old woman with multiple fractures and hypovolemic shock due to a traumatic accident; she was diagnosed with hypoxic brain injury. The second case was of a 32-year-old woman with bipolar disorder and early-onset cerebellar ataxia who developed symptoms of impaired cognition and psychosis; she was later diagnosed with autoimmune encephalopathy. In the first case, the duration between symptom onset and diagnosis was 1 day, but in the second case, it was 4 days from diagnosis based on the occurrence of high fever. We emphasize that if a young woman presents with high fever, the possibility of AAC should be considered, particularly if a CNS lesion is present because it may pose difficulty in the evaluation of typical symptoms of AAC. Careful attention is thus required in such cases.

Keywords: acalculous cholecystitis; early diagnosis; young women with CNS lesion.

Figure 1

Case #1. (a) Brain MRI (T2/FLAIR). Multiple high signal intensity on bilateral cerebral hemisphere. (b) Brain SPECT. Markedly decreased perfusion in both frontal cortex and right basal ganglia.

Figure 2

Case #1. (a,b) Abdomen-pelvic CT. the gallbladder (GB) is significantly distended, and a small amount of fluid is present in the right inferior perihepatic space, including the GB fossa. (c) Hepatobiliary US. Showing thickening of the GB wall, and the presence of amorphous echogenic sludge, considered to be a biliary sludge, inside the gallbladder.

Figure 3

Case #2. (a,b) Brain MRI (T2/FLAIR). High signal intensity on bilateral mesial temporal and occipitoparietal lobes. (c,d) Brain MRI (T1). Significant isolated cerebellar atrophy.

Figure 4

Case #2. (a,b) Abdomen-pelvic CT. the gallbladder (GB) is distended, and has a markedly diffuse-irregular wall thickening. (c) Hepatobiliary US. Showing the presence of biliary sludge inside the GB.