Acute acalculous cholecystitis: An unusual first manifestation of COVID-19

ABSTRACT

Introduction: COVID-19 pandemic has become a major global health challenge, with more than 178 million confirmed cases and over 3.86 million deaths to date. While general and respiratory symptoms are common, it may have atypical GI involvement. We chronicle here an extremely rare case of acute acalculous cholecystitis (AAC) in a patient with COVID-19. Case Description/Methods: A previously healthy 35-year-old male presented to the emergency room with abdominal pain and non-biliary vomiting. He was nonsmoker, nonalcoholic, and drugfree. His vitals revealed temperature 37.1°C, heart rate 82 bpm, blood pressure 114/72 mm Hg, respiratory rate 16/minute, and an oxygen saturation of 99% in room air. Physical examination revealed a positive Murphy's sign. Laboratory parameters revealed leukocytosis and high CRP level. Abdominal ultrasound showed marked gallbladder wall thickening, normal CBD, with no cholelithiasis or sludge formation. EUS also ruled out stones in the gallbladder. Therein, coronavirus rRTPCR came back positive. CT chest revealed bilateral patchy peripheral ground-glass opacities in the lungs, consistent with COVID-19. Based on these findings and exclusion of probable causes of AAC, COVID-19-related AAC was diagnosed. The patient was initiated on standard COVID-19 treatment for the mild disease and conservative treatment for AAC. His hospital course remained unremarkable, except for fever and dyspnea on day 4 of admission. He remained hemodynamically stable. On day 7 of admission, his abdominal pain, vomiting, and fever disappeared with treatment. On day 9 of admission, he was afebrile, dyspnea had resolved, and had no abdominal pain. He was then discharged home in a stable condition. He continues to do well for 2 months now. Discussion: Published medical literature is bereft of reports on the association between AAC and COVID-19. A PubMed search was conducted for all case reports of AAC amidst COVID-19 till June 2021. Search terms included ''acalculus cholecystitis'' and ''COVID-19''. The search resulted in only 4 case reports to date. This case highlights that the GI symptoms may precede the pulmonary manifestations of COVID-19. It further provides the clinical evidence behind a causal relationship between SARS-CoV-2 infection and biliary involvement. The extrapulmonary symptomology of this infection has not been extensively studied, warranting a high index of suspicion for rare manifestations like AAC. Thus, new-onset GI symptoms may indicate COVID-19, requiring prompt testing for SARSCoV- 2.