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 Table of Contents  
CASE REPORT
Year : 2019  |  Volume : 17  |  Issue : 4  |  Page : 417-420

Eosinophilic cholecystitis: a rare cause of acute cholecystitis ‘case report’


1 Department of Pathology, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
2 Department of Pathology and Laboratory Medicine, Prince Mishari Bin Saud Hospital, Baljurashi, Saudi Arabia

Date of Submission11-Jun-2019
Date of Decision24-Jun-2019
Date of Acceptance14-Oct-2019
Date of Web Publication14-Feb-2020

Correspondence Address:
Khalid Nafie
Prince Mishari Bin Saud Hospital, Baljurashi, Al-Baha 22888
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/AZMJ.AZMJ_82_19

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  Abstract 


We report two cases of eosinophilic acute cholecystitis in two male patients aged 43 and 20 years without peripheral eosinophilia.

Keywords: acute cholecystitis, eosinophilic, gall bladder


How to cite this article:
Hasan A, Nafie K. Eosinophilic cholecystitis: a rare cause of acute cholecystitis ‘case report’. Al-Azhar Assiut Med J 2019;17:417-20

How to cite this URL:
Hasan A, Nafie K. Eosinophilic cholecystitis: a rare cause of acute cholecystitis ‘case report’. Al-Azhar Assiut Med J [serial online] 2019 [cited 2020 Feb 29];17:417-20. Available from: http://www.azmj.eg.net/text.asp?2019/17/4/417/278401




  Introduction Top


Eosinophilic cholecystitis (EC) is a rare inflammatory condition of the gall bladder that is poorly understood [1].

The etiology of EC still remains unknown. However, it is associated frequently with other more dangerous diseases such as eosinophilic-myalgia syndrome, hypereosinophilic syndrome, parasitic infestations, and certain drugs [2]. It is clinically indistinguishable from other causes of cholecystitis [3]. Dense transmural infiltration of eosinophils that make up 90% or more of the inflammatory infiltration is the main histologic characteristic [4]. It represents 0.25 up to 6.4% of all cholecystitis [5]. Usually, EC is acalculous, but calculi are found in 40% of cases [6].


  Case history Top


We report two cases of eosinophilic acute cholecystitis in two male patients aged 43 and 20 years.

Case 1

A 43-year-old man presented with recurrent biliary colic. His investigations indicated hemoglobin 11 g/dl, total leukocyte count 4.5×103/mm3, and platelets 190×103/ul/mm3.

Ultrasound showed a picture of chronic cholecystitis with a solitary stone 2×1.5 cm in size. A diagnosis of chronic cholecystitis was made clinically. Laparoscopic cholecystectomy was performed. On gross examination, the gall bladder was 75 mm in length, with 35 mm average diameter. The average wall thickness was 12 mm with a rubbery grayish yellow cut section. Microscopically, mucosal ulceration, edema, and both acute and chronic inflammatory cell infiltrate were detected via mucosa and transmurally ([Figure 1]); there was a prominent eosinophilic infiltration ([Figure 2]) and a diagnosis of acute EC with cholelithiasis was reported.
Figure 1 Hematoxylin and eosin-stained gall bladder ulcerated mucosa with an edematous wall showing mixed inflammatory infiltrate mainly eosinophils (×40).

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Figure 2 High-power (×400) view of the inflammatory infiltrate showing prominent eosinophils.

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Case 2

A 20-year-old man presented with severe acute abdominal pain. His investigations indicated hemoglobin 12.1 g/dl, total leukocyte count 19.7×103/mm3, differential leukocyte count neutrophils 82.6%, lymphocyte 11.4%, eosinophils 4.8%, monocytes 3/mm3, and platelets 400×103/ul/mm3.

Ultrasound showed a picture of acute cholecystitis. A clinical picture of severe acute cholecystitis was recorded. Open cholecystectomy was performed. On gross examination, the gall bladder was 110 mm in length, with 40 mm average diameter. The average wall thickness was 11 mm, with a rubbery grayish yellow cut section showing blackish foci ([Figure 3]). Microscopically, severe mucosal ulceration, edematous wall with occasional acute inflammatory cells and heavy chronic inflammatory cells predominantly eosinophils were observed ([Figure 4]). A diagnosis of acute EC was reported.
Figure 3 Gross picture photo showing thickened wall and irregular mucosal surface.

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Figure 4 High-power (×200) view of the inflammatory infiltrate showing prominent eosinophils.

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  Discussion Top


The prevalence of EC ranges from 0.25 to 6.4% as reported in multiple studies across the world [1],[3],[4].

Although there are few case reports describing EC, the etiopathogenesis still remains obscure [2].

Histologically EC characterized by dense transmural inflammatory infiltrates predominated by eosinophils, which should constitute at least 90% of the infiltrates [3].

According to Dabbs[7], patients with acalculous cholecystitis are three times more likely to have EC than the patients with cholelithiasis. We report two cases: one with cholelithiasis and the other with acalculous cholecystitis.

There is no specific clinical presentation for eosinophilic cholecystitis; thus, clinically, they passed unsuspected. Histopathology remains the mainstay for the diagnosis of EC [8].

The etiology of EC is largely unknown; however, local autoimmune reactions in the gall bladder wall to the inflammatory mediators from distal regions of inflammation have been hypothesized [3]. A subset of idiopathic cases has been reported before 2014 [2], but there are many proposed etiologies that include hypereosinophilic syndrome, local allergic reaction, parasites, local diathesis involving the gall stones, eosinophilia myalgia syndrome, eosinophilic gastroenteritis, and certain drugs such as cephalosporins and herbal medicines [5],[6].

There is no evidence of any of these conditions in our two cases.

Because EC may be the presenting feature of any of these conditions, pathologists should carefully differentiate EC from other causes of cholecystitis. Also, clinicians should be meticulous with the histopathology report of routine cholecystectomy specimens and patients reported to have EC must be investigated more to rule out other associated conditions, which may have a worse prognosis than the cholecystitis itself.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Del-Moral-Martinez M, Barrientos-Delgado A, Crespo-Lora V, Cervilla-Saez-de-Tejada ME, Salmeron-Escobar J. Eosinophilic cholecystitis: an infrequent cause of acute cholecystitis. Rev Esp Enferm Dig 2015; 107:45–47.  Back to cited text no. 1
    
2.
Choudhury M, Pujani M, Katiyar Y, Jyotsna PL, Rautela A. Idiopathic eosinophilic cholecystitis with cholelithiasis: a report of two cases. Turk Patoloji Derg 2014; 30:142–144.  Back to cited text no. 2
    
3.
Caesar J, Jordan M, Hills M. Case report: a rare case of eosinophilic cholecystitis presenting after talc pleurodesis for recurrent pneumothorax. Respir Med Case Rep 2017; 20:16–18.  Back to cited text no. 3
    
4.
Sanchez-Pobre P, Lopez-Rios MF, Colina F, Yela C, Manzano M, Rodriguez S et al. Eosinophilic cholecystitis: an infrequent cause of cholecystectomy. Gastroenterol Hepatol 1997; 20:21–23.  Back to cited text no. 4
    
5.
Sahu S, Srivastava P, Chauhan N, Kishore S, Bahl DV. Eosinophilic cholecystitis: a case report. Internet J Surg 2007; 9:1.  Back to cited text no. 5
    
6.
Mohan H, Punia RPS, Dhawan SB, Ahal S, Sekhon MS. Morphological spectrum of gallstone disease in 1100 cholecystectomies in North India. Indian J Surg 2005; 67:140–142.  Back to cited text no. 6
    
7.
Dabbs DJ. Eosinophilic and lymphoeosinophilic cholecystitis. Am J Surg Pathol. 1993; 17:497–501.  Back to cited text no. 7
    
8.
Punia RP, Arya S, Jain P, Bal A, Mohan H. Eosinophilic and lympho-eosinophilic cholecystitis. Indian J Gastroenterol 2003; 22:153–154.  Back to cited text no. 8
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