Transformation of acute cholecystitis to acute choledocholithiasis in COVID-19 patient.

The global pandemic of Coronavirus 2019 (COVID-19) or SARS-CoV-2 has numerous manifestations in different organ systems. It is known that SARS-CoV-2 infects the hepatobiliary system leading to presentations such as acute cholecystitis, choledocholithiasis and hepatitis. Although the exact mechanism of the underlying pathology is unknown, it is likely attributed by the tropism of the virus to the ACE2 receptors in the hepatocytes and bile duct cells resulting in a cytokine storm that precipitates as systemic symptoms from acute COVID-19 infection. In this case report we present a case of a 47-year-old male who presented with signs consistent with acute cholecystitis. It was confirmed on ultrasound and he was incidentally found to be positive for COVID-19 on routine surveillance testing. He was asymptomatic and was being prepped for cholecystectomy, but developed an acute elevation of liver enzymes suggesting choledocholithiasis. After endoscopic retrograde cholangiopancreatography (ERCP) and cholecystectomy the patient experienced a rapid normalization of liver enzymes and improvement of his abdominal symptoms.

Chilaiditi syndrome: A structural displacement in a heart failure patient.

BACKGROUND: Chilaiditi's sign is often found incidentally on chest or abdominal radiograph and can be accompanied by clinical symptoms such as abdominal pain, gastrointestinal complications, and less commonly associated with dyspnea. CASE PRESENTATION: In this interesting case, we discover lingering dyspnea in our 79 year old male with a past medical history of asthma and heart failure with preserved ejection fraction admitted for acute heart failure exacerbation with reduced ejection fraction along with a new incidental finding of Chilaiditi's sign on chest radiograph. Patient received optimal diuretics and guideline-directed medical treatment for heart failure exacerbation, but mild dyspnea with pleuritic chest pain persisted. Dyspnea with pleurisy was likely attributed to a structural anatomical defect (Chilaiditi's sign) that can be picked up on imaging. CONCLUSION: Chilaiditi syndrome can be an incidental cause of ongoing persistent dyspnea, and if symptoms are severe, intervention can be warranted for symptomatic resolution. LEARNING OBJECTIVE: Chilaiditi syndrome should be considered as a possible diagnosis among patients with a history of heart failure and incidental Chilaiditi's sign on chest radiographic imaging who suffer from persistent dyspnea and pleurisy despite optimal diuretics and guideline-directed medical treatment.