A Rare Case of Hemorrhagic Cholecystitis in a Patient with Severe Coronavirus Disease 19 (COVID-19)

Abstract

Hemorrhagic cholecystitis is a rare end-stage manifestation of acalculous cholecystitis that is associated with high mortality. The hematological sequelae of coronavirus disease 19 (COVID-19) are complex and are associated with increased incidence of both thromboembolic and hemorrhagic events. Our patient is a 69-yearold male with hypertension and gout who was admitted to the medical intensive care unit with severe COVID-19 pneumonia and lactic acidosis. The patient was treated with a therapeutic low-intensity heparin infusion per institutional COVID-19 anticoagulation protocol based on elevated D-dimer (15,217 ng/mL). Computed tomography (CT) of the abdomen and pelvis on hospital day 1 and day 4 were negative for acute pathology. On hospital day 9, the patient developed shock and acute blood loss, and repeat CT of the abdomen showed new hemorrhagic cholecystitis. Heparin infusion was stopped, and acute care surgery consultants recommended against emergent surgery given the patient's hemodynamic instability. The patient was stabilized with blood product resuscitation and antibiotics. Laparoscopy prior to discharge showed heavy intra-abdominal adhesions with friable tissue, and the cholecystectomy attempt was aborted. He was discharged and was seen in clinic for follow-up, where he reported no abdominal pain and good functional status. Systemic coagulation dysfunction related to COVID-19 presents significant challenges to clinicians balancing the competing risks of acute thrombosis and bleeding. Hemorrhagic cholecystitis is a very uncommon complication of gallbladder disease, and reports linked to active COVID-19 are even more scarce. The gallbladder contains a particularly high expression of angiotensin I converting enzyme 2 (ACE2). This pattern is known to be vital for the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) to enter cells, but direct end-organ damage from the virus outside of the respiratory system remains an active area of research. Our patient did not have radiographic gallbladder disease present on admission, but decompensated as a result of hemorrhage early in his COVID-19 course. Here, we present an unusual manifestation of a rare disease, with spontaneous hemorrhagic cholecystitis occurring a patient with severe COVID-19.