Acute Cholecystitis Caused by Methicillin-resistant <em>Staphylococcus aureus</em>: A Rare Case Report

Case Report

Austin J Emergency & Crit Care Med. 2015;2(1): 1010.

Acute Cholecystitis Caused by Methicillin-resistant Staphylococcus aureus: A Rare Case Report

Po-An Su1,2 and Wen-Liang Yu3,4*

1Department of Internal Medicine, Section of Infectious Diseases, Chi-Mei Medical Center, Tainan

2Department of Pharmacy, Chia-Nan University of Pharmacy and Science, Taiwan

3Department of Intensive Care Medicine, Chi Mei Medical Center, Taiwan

4Department of Medicine, Taipei Medical University, Taiwan

*Corresponding author: Wen-Liang Yu, Department of Intensive Care Medicine, Chi-Mei Medical Center, 901 Chung-Hwa Road, Yungkang City, Taiwan

Received: November 21, 2014; Accepted: January 07, 2015 Published: January 09, 2015

Case Report

Acute cholecystitis is usually a mixed infection most commonly by Escherichia coli accompanied with Enterococcus species and anaerobes. Methicillin-resistant Staphylococcus aureus (MRSA) rarely causes the disease entity. However, it is uncertain whether anti- MRSA therapy should be started for acute cholecystitis for a patient with end-stage renal disease (ESRD) in the emergency medicine.

An 84-year-old man with ESRD on maintenance hemodialysis presented at the Emergency Department of our hospital with epigastric pain for one day. Other symptoms were poor appetite, nausea, vomiting and general malaise for one week. Physical examination revealed a temperature of 39.5oC, a heart rate of 94 beats per minute, a respiratory rate of 17 breaths per minute and a blood pressure of 117 /70 mmHg. Mild abdominal distension and epigastric tenderness with rebounding pain were noticed. Initial blood test revealed a white blood-cell count of 12,400/uL, a platelet count of 61,000/uL and a hemoglobin level of 10.4 g/dL. Chest X-ray revealed borderline cardiomegaly with widening and tortuosity of thoracic aorta. The computed tomography of the abdomen revealed gallstones complicated with acute cholecystitis (Figure 1). After insertion of percutaneous transhepatic gallbladder drainage (PTGBD), the patient became hypotensive and was admitted to the intensive care unit. Biochemistry data included a C-reactive protein of 166 mg/L (normal, <3); albumin, 3.1 g/dL; blood urea nitrogen, 43 mg/dL; creatinine, 4.08 mg/dL; serum glutamic-oxaloacetic transaminase, 35 IU/L; serum glutamic pyruvic transaminase, 12 IU/L; lipase, 64 IU/L; total bilirubin, 1.86 mg/dL and lactate 1.4 mmole/L. Empirical antibiotic therapy with piperacillin-tazobactam was used. The results of blood cultures were of no growth. The bile culture yielded MRSA susceptible to minocycline, tigecycline, teicoplanin, vancomycin (MIC, 1 ìg/mL) and fusidic acid, but resistant to oxacillin and clindamycin. Antibiotic was shifted to intravenous tigecycline (50 mg every 12 hours) for 1 week. The patient was getting better and transferred to general ward. He was discharged uneventfully after 10 days of hospitalization. Antibiotic was shift to oral fusidic acid (500 mg tid) for 4 weeks as prolonged antibiotic suppression therapy. One month later, T-tube cholecystography via PTGBD cholangiogram revealed filling defects in gallbladder and non-opacification of cystic duct by contrast medium (Figure 2). The patient underwent selective laparoscopic cholecystectomy after 2 months of discharge. Multiple black pigmented stones in the thicken-wall gallbladder with sticky pus formation were found and pathology of gallbladder confirmed acute cholecystitis with cholelithiasis.

Citation: Po-An Su and Wen-Liang Yu. Acute Cholecystitis Caused by Methicillin-resistant Staphylococcus aureus: A Rare Case Report. Austin J Emergency & Crit Care Med. 2015;2(1): 1010 ISSN:2380-0879