PMC7733147_01
Patient's clinical course during the initial 24 h after arrival. The core temperature was lowered to 38 C (red dotted oval), while the systolic pressure recovered to above 100 mmHg (green dotted oval) for 90 min following cooling and cold fluid infusion. Although the immediate cooling and stabilization of circulation for heat stroke was successful, improvement in the lactate (Lac) level was limited. Because of the prolonged shock and disseminated intravascular coagulation (DIC), she was treated by massive fluid infusion and anti-DIC therapy (17,100 U/day of thrombomodulin alfa and 1,500 U/day of antithrombin III). Acute diarrhea was observed 10-20 h after arrival. The patient progressed into hypotension and hyperthermia 22 h after her arrival, and she was diagnosed with septic shock caused by emphysematous cholecystitis. Laboratory investigations revealed elevated Lac and procalcitonin (PCT) levels, DIC, and decreased white blood cell (WBC) count. CRP, C-reactive protein; EC, emphysematous cholecystitis, Lac, lactate, PCT, procalcitonin, WBC, white blood cell.
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The patient was treated for 24 h with 6,200 mL of fluid infusion; the total urinary output was 1,800 mL with acute diarrhea (Fig. 1). After 22 h of arrival at our hospital, the patient's blood pressure decreased to 72/50 mmHg, while her fever increased to 40.6 C (Fig. 1).
Emergency cholecystectomy performed following patient diagnosis with emphysematous cholecystitis (EC) on day 2. A, EC (white triangle heads) was identified using an abdominal X-ray examination. B and C, The gallbladder X-ray revealed ischemic changes, including enlargement, edema, dark red coloration, and emphysematous changes on the gallbladder wall. Inflammation of the gallbladder affected the neighboring liver and duodenum. The bile culture indicated presence of Clostridium perfringens. D and E, Histological findings of gallbladder using hematoxylin and eosin stain showed amorphous cystic spaces (black arrows), possibly resulting from proliferation of gas-forming bacteria, and hemorrhage and necrotic changes with bacterial colonies (yellow triangle heads).
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Although the physical examination of right upper quadrant abdominal pain and signs of peritoneal irritation was unclear, an abdominal X-ray examination indicated emphysematous cholecystitis (Fig. 2). Inflammation of the gallbladder affected the neighboring liver and duodenum (Fig. 2).