Cytomegalovirus Cholangiopathy in an Immunocompetent Patient: A Case Report and Literature Review

A 37-year-old man presented with jaundice, upper right quadrant pain, and intermittent fever with chills. Laboratory assessment showed biliary stasis, with total bilirubin of 203 µmol/L (2–20), conjugated bilirubin of 105 µmol/L, and alkaline phosphatase of 556 U/L (30–120). Markers for hepatitis A–E viruses were negative. Serology assessment for rubeola, herpes simplex virus, Epstein-Barr virus, and Toxoplasma gondii showed negative IgM antibodies. HIV serology status was negative. For cytomegalovirus, both types of antibodies (IgM and IgG) were positive, with an IgM level >300 U/mL. pp65 antigen was also detected as well as CMV DNA. Diagnostic imaging of the abdomen except the dilated common bile duct showed a normal appearance of the gallbladder, liver, pancreas, spleen, and both kidneys. To our knowledge, cytomegalovirus cholangiopathy in the absence of any other underlying disease has not been reported. Therefore, the presence of cholangiopathy in our patient is interesting from an imaging, laboratory, and clinical point of view.

Acute fasciolosis in an alpaca: a case report

Background The popularity of new world camelids, particularly alpacas, is growing rapidly in Ireland, presenting a clinical challenge to veterinary practitioners who may not have worked with these species previously. To the authors’ knowledge, the clinical course of a case of acute fasciolosis in an alpaca has not previously been reported, and fasciolosis has not been reported at all in alpacas in Ireland, making this case report a valuable addition to the current literature. Case presentation A three-year-old male castrated huacaya alpaca was admitted to UCD Veterinary Hospital with a two-day history of colic and tenesmus. He had been treated with albendazole, dexamethasone and potentiated amoxycillin by the referring veterinary practitioner with no response. On initial clinical exam, sensitivity to abdominal palpation was the only abnormality. However, the alpaca proceeded to show abnormal lying positions, tenesmus and reduced faecal output over the next 24 h. A general blood panel demonstrated moderate anaemia, marked hyperglobulinaemia and moderately increased hepatocellular and hepatobiliary enzyme activity. Abdominal radiography revealed enlargement of the first forestomach compartment without evidence of gastrointestinal obstruction or peritonitis. An abdominal ultrasound exam revealed an elongated, heterogenous mass in the caudoventral abdomen that appeared to be contiguous with the liver. FNA of this mass revealed that it was in fact a liver lobe with biliary stasis and inflammation. Faecal sedimentation demonstrated Fasciola hepatica eggs. In spite of treatment with triclabendazole and supportive treatment including blood transfusion, the alpaca’s condition continued to deteriorate and he was euthanised. On post-mortem exam, acute fasciolosis was diagnosed. Conclusions The clinical presentation and course of a case of acute fasciolosis in an individual alpaca is described, including the results of a range of diagnostic tests that were carried out. The final diagnosis is supported by a description of post-mortem findings. This information will serve as a resource for veterinary practitioners involved in the diagnosis and treatment of similar cases.

A RARE CASE OF HETEROPHILE NEGATIVE EBV VCA IGM POSITIVE INFECTIOUS MONONUCLEOSIS COMPLICATED BY COLD AUTOIMMUNE HEMOLYTIC ANEMIA

Infectious mononucleosis (IM) is often an uncomplicated self-limited illness resulting from Epstein-Barr virus (EBV) in 90% cases. This is a case report of 21-year-old female whose initial clinical and laboratory presentation suggested Heterophile antibody negative Epstein–Barr Viral capsid Antigen (VCA) IgM positive infectious Mononucleosis. Our case was complicated by biliary stasis, cold autoimmune hemolytic anemia with acrocyanosis, thrombocytopenia and some of the features of hemophagocytic lymphohistiocytosis (HLH). Following symptomatic management patient recovered. Physicians should routinely counsel their patients with IM for these complications and should avoid overzealous treatment

Retroperitoneal perforation of a duodenal diverticulum containing a large enterolith after Roux-en-Y bypass and cholecystectomy

Roux-en-Y gastric bypass (RYGB) is one of the most frequently performed bariatric procedures worldwide. The postoperative incidence of cholelithiasis after RYGB is higher than in the general population (30% vs. 2–5%), because the altered anatomy may lead to impaired gallbladder motility and biliary stasis. We report the case of a 47-year-old female who presented 9 years after RYGB and cholecystectomy with acute pain in the upper abdomen because of a retroperitoneal perforation of a duodenal diverticulum. Intraoperatively, a huge enterolith was found in the diverticulum and removed via duodenotomy. We claim that the stone grew during the sober states as the bile accumulated locally, because the gall bladder has already been removed and no duodenal food passage remained. This acute and life-threatening situation was successfully managed by operation. Consequently, a duodenal diverticulum has to be considered as a possible but very rare complication after RYGB and cholecystectomy.

Management of afferent loop syndrome after Roux-en-Y subtotal gastrectomy and choledocolithiasis with recurrent cholangitis

Afferent loop syndrome is a rare complication after gastrectomy with Billroth II or Roux-en-Y reconstruction, caused by an obstruction in the proximal loop. The biliary stasis and bacterial overgrowth secondary to this obstruction can lead to repeated episodes of acute cholangitis. We present the case of a male patient who had previously undergone gastrectomy with Roux-en-Y reconstruction and later experienced multiple episodes of acute cholangitis secondary to choledocolithiasis. He underwent an open exploration of the bile ducts with choledocolitotomy, but the events of cholangitis persisted. Further investigation permitted to identify a dilation of the biliary loop of the Roux-en-Y anastomosis, suggesting enterobiliary reflux as the cause of recurrent acute cholangitis. Therefore, a bowel enterectomy and new jejunojejunostomy were undertaken, and normal biliary flow was re-established. The surgical treatment is mandatory in benign causes, leading to the resolution of the obstruction and subsequent normalisation of bile flow.

Clinical and Paraclinical Considerations Regarding Acute Cholecystitis

The gallbladder represents a vast pathological subject, vastly disputed because of the many diseases and conditions that can develop. One of the diseases of the bladder is acute cholecystitis, a pathological entity that is induced by the acute inflammation of the gallbladder. It is of particular interest to the patients that present gallstones, with a prevalence of 10 to 25% of the total surgical interventions regarding the gallbladder diseases.The objective of this article is to analyze the diagnosis and treatment of acute cholecystitis and highlight the importance of diet in this pathology.The incriminating factor of acute cholecystitis is the biliary stasis, along with bacterial infections that also intervene and the possible ischemia of the bladder wall. In about 90 to 95% cases the biliary stasis is a follow up to the calculous obstruction of the cystic duct, context in which patients are diagnosed with acute lithiasic cholecystitisUnder antibiotic therapy clinical improvement occurs rarely, most often a stationary phase of acute cholecystitis settles in. The unfavorable evolutions refer to patients who develop complications. Bile peritonitis which may be generalized or localized, most often a localized peritonitis occurs, which will develop a plastron in a few days that acts as an armor, is even to touch and presents a dull percussionConclusions. Acute cholecystitis is a common disease in clinical practice, and most often it represents a surgical emergency. The quality of life of a patient that suffers from gallbladder diseases may be affected, as they must follow a certain diet.

Identifying and Treating Ascending Cholangitis: A case report and review of literature.

Acute cholangitis is an infection of the biliary system that typically results from obstruction. Common causes include choledocholithiasis, strictures, foreign bodies (such as biliary stents) parasitic worms (e.g. ascarids) and compression from an external structure. Obstruction allows for higher bacterial concentrations and bacterial proliferation. With biliary stasis and increases in intraductal pressure, bacteria migrate into the venous and lymphatic systems with subsequent bacteremia. The rate of gallstone development is 3-4 % annually in those >60 years old with up to a 15% overall prevalence in the US. In the US, 85% of ascending cholangitis cases are a consequence of choledocholithiasis. The gram-negative bacteria E coli, Klebsiella, Pseudomonas and Enterobacter are the most commonly identified pathogens. Anaerobes are less common.Ascending cholangitis is classically diagnosed by the presence of Charcot’s triad – fever, right upper quadrant pain and jaundice. Though very specific, the presence of Charcot’s triad is only 26% sensitive and thus its absence does not rule out the diagnosis. All patients with suspected ascending cholangitis should undergo appropriate fluid resuscitation, be given broad spectrum antibiotics to cover the likely enteric pathogens, and closely monitored for worsening in their clinical condition.Once initial assessment is complete and resuscitative efforts begun, imaging is often helpful in confirming the diagnosis of ascending cholangitis. After the diagnosis has been confirmed, ERCP and biliary drainage is indicated.

Identifying and Treating Ascending Cholangitis. A case report and review of literature.

Acute cholangitis is an infection of the biliary system that typically results from obstruction. Common causes include choledocholithiasis, strictures, foreign bodies (such as biliary stents) parasitic worms (e.g. ascarids) and compression from an external structure. Obstruction allows for higher bacterial concentrations and bacterial proliferation. With biliary stasis and increases in intraductal pressure, bacteria migrate into the venous and lymphatic systems with subsequent bacteremia. The rate of gallstone development is 3-4 % annually in those >60 years old with up to a 15% overall prevalence in the US. In the US, 85% of ascending cholangitis cases are a consequence of choledocholithiasis. The gram-negative bacteria E coli, Klebsiella, Pseudomonas and Enterobacter are the most commonly identified pathogens. Anaerobes are less common.Ascending cholangitis is classically diagnosed by the presence of Charcot’s triad – fever, right upper quadrant pain and jaundice. Though very specific, the presence of Charcot’s triad is only 26% sensitive and thus its absence does not rule out the diagnosis. All patients with suspected ascending cholangitis should undergo appropriate fluid resuscitation, be given broad spectrum antibiotics to cover the likely enteric pathogens, and closely monitored for worsening in their clinical condition.Once initial assessment is complete and resuscitative efforts begun, imaging is often helpful in confirming the diagnosis of ascending cholangitis. After the diagnosis has been confirmed, ERCP and biliary drainage is indicated.

Biliary ascariasis presenting with gangrenous perforation of the gall bladder: report of a case and brief review of literature

The most common cause of gallbladder perforation is calculous cholecystitis. Rarer causes include trauma, iatrogenic injuries, biliary stasis and gall bladder ischemia. We report a case of gall bladder gangrene with perforation, secondary to extensive ascariasis. A 45-year-old woman presented with acute intestinal obstruction and jaundice. She had abdominal distension and right hypochondrial tenderness. Abdominal radiography showed dilated bowel loops and ultrasonogram showed worms in the small intestine and biliary tree. On exploration, a bolus of worms 2 feet proximal to the ileocaecal junction was found causing obstruction. Worms were also present in the bile duct and gallbladder causing gangrene and perforation. She underwent cholecystectomy, bile-duct exploration and enterotomy. However, she died on the third postoperative day of overwhelming sepsis. Enteric complications of ascaris leading to bowel obstruction are well-known. Hepatobiliary complications such as cholangitis and obstructive jaundice are rare. However, such an extreme degree of infestation leading to gangrene and perforation of the gall bladder is extremely rare.