Abstract
To the Editor:
P
A 59-year old male with hypertension and ischemic cardiomyopathy with an ejection fraction of 25% was admitted with a one-day history of post-prandial abdominal discomfort in the right hypochondrium and feelings of bloating for the past few years. On admission, he had a fever with rigor and tachypnea. Abdominal examination revealed tenderness in the right upper quadrant and a positive Murphy's sign of acute cholecystitis. Serum investigations revealed an elevated white blood cell count and deranged liver enzymes. A magnetic resonance cholangiopancreatography scan showed gallstones, pericholecystic fat stranding, and a 7.7 × 5.6-cm rim-enhancing fluid collection adjacent to the gallbladder suggestive of perforation. The common bile duct was 7 mm in diameter. The diagnosis of severe AC with perforation was made.
Urgent percutaneous cholecystostomy was performed at which 40 mL of dirty bile was drained, and the fluid grew P. gergoviae sensitive to amoxicillin/clavulanic acid. Antibiotic therapy was guided by the antibiotic stewardship team and de-escalated after a week of administration by the intravenous route. In view of recent coronavirus 2019 (COVID-2019) disease, he was categorized as C because of his high cardiac risk and hence was not prioritized for surgical intervention [2]. He remains well in the community and free from sepsis.
Pluralibacter gergoviae infections are rare, with sporadic reports of endophthalmitis, osteomyelitis, and urinary tract infections attributable to the organism [3]. To date, P. gergoviae infection causing AC has never been reported. A PubMed search done on 18 January 2020 with the terms “Pluralibacter gergoviae” and “Enterobacter gergoviae” yielded two and 53 results, respectively. These infections are reported more frequently among children and patients infected with human immunodeficiency virus [4]. Other risk factors are the presence of a foreign device and previous antibiotic usage as well as of cosmetic skin products [1,3]. Our patient did not have any foreign device or previous antibiotic exposure and tested negative for the retrovirus. He also did not report use of cosmetic skin care products.
Acute cholecystitis is a common surgical emergency with antibiotics and index admission cholecystectomy being accepted standards of care. Empiric antibiotics based on the local antibiogram are sufficient. Enterobacter gergoviae strains typically are resistant to penicillin, oxacillin, and cefoxitin. In our patient, P. gergoviae was sensitive to all tested antibiotics except cefoxitin.
Perforated cholecystitis has significant morbidity and mortality rates. In patients with mild to moderate cholecystitis, index admission laparoscopic cholecystectomy not only reduces the length of stay and cost, but also restores the quality of life. In patients with complications such as perforation or with organ failure attributable to sepsis, percutaneous cholecystostomy is preferred. Once sepsis resolves, elective laparoscopic cholecystectomy can be offered in selected patients. However, it is worthwhile to note that subsequent cholecystectomy is associated with a high risk of requiring open conversion as well as of morbidity andcommon bile duct injury.
Pluralibacter gergoviae causing AC is reported for the first time. We are unable to trace links with cosmetic products, as we had not tested for them.