Amar M. Taksande

Arvind Kumar

K.Y. Vilhekar

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Case ReportJ Vector Borne Dis 45, March 2008, pp. 76–77Acalculous cholecystitis by P. falciparum in a 3-year old childArvind Kumar, Amar M. Taksande & K.Y. VilhekarDepartment of Pediatrics, Mahatma Gandhi Institute of Medical Sciences, Wardha, IndiaKey words  Acalculous – cholecystitis – falciparum malariaAcute cholecystitis involves inflammation of thegallbladder and can be seen with cholelithiasis (cal-culous) or in the absence of gallstones (acalculous).Acute acalculous cholecystitis (ACC) is rare, butimportant cause of cholecystitis in pediatrics1. It isestimated that in children, 30–50% of cholecystitiscases are acalculous, compared with 2 to 17% ofcases in adult patients2. In children ACC mainly re-sult from antecedent bacteremia and localization ofbacteria in the gallbladder. So the majority cases havebeen managed by medical treatment alone. Gas-trointestinal manifestations are common in malaria3,but the ACC is extremely a rare manifestation ofmalaria and a very few cases have been reported pre-viously. Here we report a case of ACC attributed tosevere Plasmodium falciparum malaria infection ina 3-year old child.A 3-year old female child presented with history ofintermittent fever since five days associated with rig-ors. History of abdominal pain and vomiting waspresent. Vomiting was non-projectile and non-bil-ious. On physical examination she was irritable, tem-perature 39°C, pulse rate 120/min, respiratory rate28/min and blood pressure 96/60 mm Hg. She wasseverely pale. Icterus, cyanosis or lymphadenopathywas absent. On per abdomen examination revealedtenderness in right upper quadrant. Hepatosplenom-egaly was present. Murphy’s sign was positive. Othersystemic examinations were normal.On investigation, peripheral smear showed a ringstage of P. falciparum and the parasite density was50,000/μl. The rapid diagnostic test (antigen HRP2)for P. falciparum was positive. Complete blood cellcount showed a hemoglobin 5.4 g%, WBC 14100 cu/μl (85% polymorphs, 42% lymphocytes, 2% eosino-phils and 1% monocytes), hematocrit 17.5, plateletcount 56,000/mm3. Liver function and renal functiontests were within normal limit. Widal test was non-reactive. Blood and urine culture were sterile. Hemo-globin electrophoresis was AA type. USG abdomenrevealed thickened gallbladder (wall thickness was 6mm) and hepatosplenomegaly. No abnormality de-tected on X-ray abdomen and chest. Child was put onIV antibiotics and antimalarial (artesunate) drug.Packed-cell blood transfusion was given. On the basisof clinical and USG findings the diagnosis of acutecholecystitis was made. After five days of treatment,child condition was improved.ACC has been reported with various infectious agentslike Salmonella typhi, Escherichia coli, Mycoplasmapneumoniae, leptospirosis, brucellosis, rocky moun-tain spotted fever, group A streptococci, and Staphy-lococcus aureus sepsis. In immunocompromisedhosts, acalculous cholecystitis has been reported infungal infection with Candida or Aspergillus, Giar-dia and Cryptosporidium1. The diagnosis of ACC wasmade according to clinical features and sonographicfindings. The clinical manifestations were fever, rightKUMAR et al: ACALCULOUS CHOLECYSTITIS BY P.  FALCIPARUM  77upper quadrant tenderness, and a positive Murphy’ssign. Sonographic findings were a thickened gallblad-der wall (defined as wall thickness > 4 mm) in ab-sence of ascitis and hypoalbuminemia, a positivesonographic Murphy’s sign (defined as maximumtenderness of the sonographically localized gallblad-der), pericholecystic fluid collection, and no stone(s)in the gallbladder4. Patients had no recent history ofburns, trauma, vasculitis, or recent surgery.The exact pathogenesis of ACC is not clearly under-stood, but cholestasis and increased bile viscosityfrom prolonged fasting, spasm of the ampulla ofvater, endotoxemia, microangiopathy and ischemic-reperfusion injury, among the other causes have beensuggested5-7. Intense sequestration of parasite in vas-cular endothelium, visceral ischemia and increasedvascular permeability8, are well-known pathogenesesof falciparum malaria responsible for major gas-trointestinal manifestations. Similarly, it appears tobe responsible for the pathogenesis of acute cholecys-titis in our case. The other possible reason for ACCin falciparum malaria could be Salmonella infection,as it is related to a transient immunosuppression in-duced by malaria9, but in our case blood culture wasnegative. So in this case the former mechanism ap-pear to be involved for the pathogenesis of ACC.Although the pathogenesis of ACC remains contro-versial, malaria should be included in the differentialdiagnosis of ACC, especially in endemic zones ofmalaria.References1. Soden J, Karpen SJ. Cholangitis and cholecystitis. In:Feigin, Cherry, Demmler, Kaplan, editors. Textbook ofpediatric infectious diseases. V edn. Philadelphia:Saunders 2004; p. 675–6.2. Tsakayannis DE, Kozakewiich HP, Lillehei CW. Acalcu-lous cholecystitis in children. J Pediatr Surg 1996; 31:127–31.3. Murphy GS, Oldfield EC III. Falciparum malaria. InfectDist Clin North Am 1996; 10: 751–2.4. Bilhart LE. Acalculous cholecystitis, adenomatosis, cho-lesterosis, and polyps of the gallbladder. In: SlieisengerMH, Fordtran JS, editors. Gastrointestinal and liver dis-ease. VI edn. Philadelphia: Saunders 1999; p. 993–1005.5. Shapiro MJ, Luchtefeld WB, Kurzurki JE. Acuteacalculous cholecystitis in the critically ill. Am Surg 1994;60: 335–9.6. Hakala T, Nuutinen PJO, Roukonen ET, Alhava E. Micro-angiopathy in acute acalculous cholecystitis. Br J Surg1997; 84: 1249–2.7. Savoca PE, Lryo WE, Pastemark B, Gusberg RJ. Dosevisceral ischemia plays a role in the pathogenesis ofacalculous cholecystitis? J Clin Gastroenterol 1990; 12:33–6.8. White NJ. Malaria. In: Gordon C, Cook Z, Alimuddin, edi-tors. Mamon’s Tropical Diseases, XXI edn. London:Saunders 2003; p. 1223–5.9. HOM, Webster HK.T-cell response in acute falciparummalaria. Immunol Lett 1990; 25: 135–8.Corresponding author: Dr Arvind Kumar, Department of Pediatrics, Mahatma Gandhi Institute of Medical Sciences,Sevagram, Wardha– 442 102, India.E-mail: dravind79@rediffmail.comReceived: 19 October 2007 Accepted: 29 November 2007

Acalculous cholecystitis by P. falciparum in a 3-year old child

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