Letters to the Editor

Shu Tanaka,* Keigo Mitsui,* Katsuro Shirakawa,† positive, confirming an acute dengue infection. Computed tomog-
Atsushi Tatsuguchi,* Tetsuya Nakamura,† raphy (CT) scan performed on admission demonstrated a gallblad-
Yoshikazu Hayashi, Masakazu Jakazoe,§ Choitsu Sakamoto* and
‡
der with a markedly thickened wall associated with surrounding
Akira Terano† adjacent fluid collection compatible with acute cholecystitis
*Department of Medicine, Division of Gastroenterology, Nippon (Fig. 1). There were no gallstones visualized and there was also a
Medical School, Tokyo, †Department of Endoscopy, Dokkyo small right-sided pleural effusion. The other abdominal organs
University School of Medicine, Tochigi, ‡Department of Internal including the liver, spleen, pancreas and kidneys were unremark-
Medicine, Division of Gastroenterology, Jichi Medical School, able. A CT scan was performed instead of an abdominal ultra-
Tochigi and §Department of Internal Medicine, Social Insurance sound (US) as CT scanning is more readily available at our
Chuo General Hospital, Tokyo, Japan institution (especially after work hours).
The patient was initially managed conservatively and her
platelet count rose gradually to 75 × 109/L on the fourth day of
References hospitalization, which was compatible with a self-limiting throm-
1 Iddan G, Meron G, Glukhovsky A, Swain P. Wireless capsule endos- bocytopenia secondary to an acute viral infection. However, the
copy. Nature 2000; 405: 417. patient remained febrile and her abdominal tenderness did not
2 Eliakim R, Fischer D, Suissa A et al. Wireless capsule video endoscopy improve, therefore, an emergency exploratory laparotomy was
is a superior diagnostic tool in comparison to barium follow-through performed on the fourth day of hospitalization. Intraoperatively,
and computerized tomography in patients with suspected Crohn’s dis-
the findings were that of an acutely inflamed and edematous gall-
ease. Eur. J. Gastroenterol. Hepatol. 2003; 15: 363–7.
3 Yamamoto H, Sekine Y, Sato Y et al. Total enteroscopy with a
bladder compatible with acute cholecystitis. There were no gall-
nonsurgical steerable double-balloon method. Gastrointest. Endosc. stones. Open cholecystectomy was performed and the final
2001; 53: 216–20. histological findings confirmed the diagnosis of acalculous chole-
4 Arifuddin RM, Baichi MM, Mantry PS. Small bowel capsule impaction cystitis. The patient’s postoperative recovery was uneventful and
and successful endoscopic retrieval. Clin. Gastroenterol. Hepatol. she was discharged in a well state on the third postoperative day.
2005; 3: 34. Her platelet count had risen to 127 × 109/L on the day of discharge.
5 Gay G, Delvaux M, Laurent V et al. Temporary intestinal occlusion Upon review at the outpatient clinic 2 weeks after discharge, the
induced by a ‘patency capsule’ in a patient with Crohn’s disease. Endo- patient was well and her platelet count had normalized.
scopy 2005; 37: 174–7. Dengue is a mosquito-borne viral disease caused by the dengue
virus, a member of the Flaviviridae family, which occurs as four
antigenically related but distinct serotypes.1 It is endemic in
Blackwell Publishing AsiaMelbourne, AustraliaJGHJournal of Gastroenterology and Hepatology0815-93192005 Blackwell Publishing Asia Pty Ltd tropical countries in Asia, Africa and South America and may
2005 21922926Letter to the EditorLetters to the EditorLetters to the Editor
present with a wide spectrum of clinical manifestations ranging
LETTER TO THE EDITOR from a clinically unapparent infection to a potentially lethal dis-
ease.1,2 The common clinical features include fever, headache,
Case of dengue virus infection mylagia, arthralgia, nausea, vomiting, rash and minor hemorrhagic
presenting with acute acalculous manifestations such as petechiae and epistaxis. In endemic
cholecystitis regions, the diagnosis of dengue infection should always be con-
sidered in patients presenting with abdominal pain and fever.3
To the Editor, Dengue infection can be classified according to its severity into
A 59-year-old female presented with acute onset of right hypo- dengue fever (DF), dengue hemorrhagic fever (DHF) and dengue
chondrium (RHC) pain and fever of 5-days’ duration. On physical shock syndrome (DSS).4 Occasionally, dengue infection may
examination, she was hemodynamically stable but was febrile. present with atypical manifestations including severe hemorrhage,
There was no visible rash and the patient had no recent contact fulminant liver failure, cardiomyopathy and encephalopathy.1,5,6
history with dengue patients. Abdominal examination revealed a Reports of dengue complicated by acalculous cholecystitis are
tender RHC associated with a positive Murphy’s sign. Laboratory unusual2 and acalculous cholecystitis as an initial presentation of
and hematological investigations were as follows: hemoglobin dengue is even rarer.3,5,7 However, this complication may be more
14.3 g/dL, platelets 6 × 109/L, white cell count 3.41 × 109 with common than previously suspected. Recently, Khanna et al.
49% neutrophils, creatinine 94 µmol/L, urea 4.6 mmol/L, serum reviewed 20 patients in India with DF presenting with abdominal
alkaline phosphatase 437 U/L, alanine transaminase 215 U/L and pain and fever and they found two patients (10%) with acalculous
aspartate transaminase 418 U/L. The rest of the biochemical inves- cholecystitis.3 Another retrospective review conducted in Taiwan
tigations including the electrolyte panel, serum amylase and coag- revealed that 10 of 131 DF patients (7.6%) had complications of
ulation profile were normal. acute acalculous cholecystitis.2 However, it did not distinguish the
A clinical diagnosis of acute cholecystitis with severe sepsis patients who actually presented with cholecystitis from those who
was made with a differential diagnosis of a viral infection such as developed the complication during the course of the disease. In
dengue (due to the low platelet count). The patient was started on this report, we discussed another case of DF presenting atypically
empiric broad-spectrum antibiotics. The blood and urine cultures with acute acalculous cholecystitis.
obtained on admission did not reveal any bacterial growth. Dengue The diagnosis of acalculous cholecystitis in dengue should be
serology via enzyme-linked immunoabsorbent assay (ELISA) for made based on its typical clinical features such as RHC pain and
dengue IgM antibodies (Dengue Fever Virus IgM Capture DxSe- a positive Murphy’s sign. One should always be cautious when
lect kit, Focus Technologies, Plano, Texas, USA) was strongly interpreting cross-sectional imaging findings, as a thickened

Journal of Gastroenterology and Hepatology 21 (2006) 922–926 923

© 2006 Journal of Gastroenterology and Hepatology Foundation and Blackwell Publishing Asia Pty Ltd
Letters to the Editor
Figure 1 Computed tomography (CT) scan of the patient demonstrat-
ing the gallbladder with thickened wall and pericholecystic fluid collec-
tion suggestive of acute cholecystitis.
gallbladder wall is commonly found in DF. In fact, a thick-walled
gallbladder has been reported to be the most common abdominal
US finding in DF, occurring in 43–59% of patients.8,9 Due to
the frequency of this finding, some investigators have even pro-
posed that US be used as a first-line diagnostic imaging modality
in patients with suspected DF.8 Other commonly reported
findings on abdominal US include pleural effusion, ascites and
splenomegaly.8,9
The pathophysiology of acute acalculous cholecystitis in den-
gue is unknown. Some have suggested a direct invasion of the
gallbladder wall by the virus, but thus far there is little pathologi-
cal evidence to support this hypothesis.2 Another possible explana-
tion is infection of the thickened edematous gallbladder wall by
gut bacteria. As with other critically ill patients, acute acalculous
cholecystitis may also theoretically occur in patients with severe
DHF due to ischemic-reperfusion injury, cholestasis and increased
bile viscosity secondary to prolonged fasting and endotoxemia.
The initial management of acalculous cholecystitis in DF
should be conservative.2 This is because the gallbladder inflamma-
tion in these patients is frequently self-limiting and will resolve
as the patient recovers from DF.2 Furthermore, these patients
frequently have a high tendency for hemorrhagic complications
due to their low platelet count, making early surgery hazardous.
Nonetheless, surgical intervention may be unavoidable in selected
cases, especially if diffuse peritonitis sets in or there is a high
suspicion of gallbladder perforation or gangrene. In this instance,
cholecystectomy or percutaneous cholecystostomy can be per-
formed depending on the fitness of the patient.2 If the platelet
count is low, platelets should always be transfused perioperatively
to reduce the risk of intra- or postoperative bleeding. In the present
case, open cholecystectomy was performed as the patient’s condi-
tion did not improve with conservative management. Fortunately,
when the patient underwent surgery she was already in the conva-
lescent stage of DF and her platelet count was on the upward trend.
This case provides further evidence supporting the notion that
patients with dengue complicated by acalculous cholecystitis
should be managed conservatively initially. Delaying surgical
924
© 2006 Journal of Gastroenterology and Hepatology Foundation and Blackwell Publishing Asia Pty Ltd
intervention may allow the operative procedure to be performed
when the patient is in a ‘less critical’ phase of the disease.
In conclusion, we have reported a case of acute acalculous
cholecystitis as an atypical presentation of dengue. It is imperative
that clinicians consider this diagnosis in patients or travelers from
areas endemic for dengue who present with typical features of
acute cholecystitis, especially when radiological imaging demon-
strate the absence of gallstones and the platelet count is low.
Brian KP Goh and Seck-Guan Tan
Department of Surgery, Singapore General Hospital, Singapore
References
1 Mairuhu AT, Wagenaar J, Brandjes PM, van Gorp EC. Dengue: an
arthropod-borne disease of global importance. Eur. J. Clin. Microbiol.
Infect. Dis. 2004; 23: 425–33.
2 Wu KL, Changchien CS, Kuo CM et al. Dengue fever with acute
acalculous cholecystitis. Am. J. Trop. Med. Hyg. 2003; 68: 657–60.
3 Khanna S, Vij JC, Kumar A, Singal D, Tandon R. Dengue fever if a
differential diagnosis in patients with fever and abdominal pain in an
endemic area. Ann. Trop. Med. Parasitol. 2004; 98: 757–60.
4 World Health Organization. Dengue Hemorrhagic Fever: Diagnosis,
Treatment, Prevention and Control, 2nd edn. Geneva: WHO, 1997.
5 Sood A, Midha V, Sood N, Kaushal V. Acalculous cholecystitis as an
atypical presentation of dengue fever. Am. J. Gastroenterol. 2000; 95:
3316–17.
6 Nimmannitya S, Thisyakorn U, Hemsrichart V. Dengue haemorrhagic
fever with unusual manifestations. Southeast Asian J. Trop. Med. Public
Health 1987; 18: 398–406.
7 Van Troys H, Gras C, Coton T, Deparis X, Tolou H, Durand JP.
Imported dengue hemorrhagic fever: description of 1 case presenting
with signs of acute alithiastic cholecystitis. Med. Trop. (Mars) 2000; 60:
278–80.
8 Wu KL, Changchien CS, Kuo CH et al. Early abdominal sonographic
findings in patients with dengue fever. J. Clin. Ultrasound 2004; 32:
386–8.
9 Thulkar S, Sharma S, Srivastava DN, Sharma SK, Berry M,
Pandey RM. Sonographic findings in grade III dengue hemorrhagic
fever in adults. J. Clin. Ultrasound 2000; 28: 34–7.
Blackwell Publishing AsiaMelbourne, AustraliaJGHJournal of Gastroenterology and Hepatology0815-93192005 Blackwell Publishing Asia Pty Ltd
2005 21922926Letter to EditorLetters to the EditorLetters to the Editor
LETTER TO THE EDITOR
Jejunojejunal intussusception
secondary to a jejunal lipoma in an adult
To the Editor,
Intussusception is a prolapse of a segment of the intestine into the
lumen of adjacent intestines. The majority of intussusceptions
occur in infancy and early childhood, and rarely in adults. The
underlying causes of intussusception in an adult vary greatly.
Lipoma is not a common tumor in the gastrointestinal tract, and
gastrointestinal lipomas may be submucosal or subserosal. Most
of them are asymptomatic although they may cause abdominal
pain, bowel obstruction, and gastrointestinal bleeding. Intestinal
intussusception caused by lipoma is uncommon. It is particu-
larly rare when lipoma is located in the small intestine. We
present a rare case of jejunojejunal intussusception due to lipoma
Journal of Gastroenterology and Hepatology 21 (2006) 922–926