BMJ Case Reports 2011; doi:10.1136/bcr.08.2010.3292
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This case is an excellent example of what fi rst appeared
to be a simple (yet serious) case of a common surgical
condition having a complex underlying aetiology. It also
elegantly demonstrates that simple routine examination as
well as investigation of more subtle symptoms can lead to
the unravelling of such complex cases and the institution
of effective treatment. Effi cient treatment involved several
disciplines spanning the medicine–surgery spectrum and
both secondary and tertiary care.
This case confi rms a previously reported yet very rare
association of listeriosis and cholecystitis and the more
common yet still infrequent association of HIV and liste-
riosis. It also introduces a formerly unreported association
of HIV, listeriosis and cholecystitis.
A 37-year-old woman of Tanzanian origin presented to the
accident and emergency department with abdominal pain,
fever and two episodes of loose stools after 4 days of shak-
ing and feeling generally unwell. The pain was of sudden
onset and stabbing in nature, waking her from sleep with
a severity of 10/10. It was located in the right upper quad-
rant and did not radiate. It was worsened by movement
Her medical history was unremarkable except for acne
that was being treated with Roaccutane, which she had
stopped taking when she fi rst felt unwell.
She has two children who live in Tanzania, whom she
last visited 3 years ago; she had no other recent travel. She
was working as a healthcare assistant and living locally in
a fl at with friends. She does not drink or smoke.
On initial examination she was febrile (40.3°C),
tachycardic (160 beats per minute) and hypotensive
(109/70 mm Hg). Her oxygen saturation was well main-
tained and she was not tachypnoeic. Her abdomen was
tender in the right hypochondrium and Murphy’s sign
was positive. Oral examination revealed white plaques.
Respiratory and cardiovascular exams were otherwise
Admitting blood tests found C reactive protein 340 mg/l,
white cell count 7.6×10 3 /mm 3 , haemoglobin 9.7 g/dl
and platelets 210×10 3 /mm 3 . Over 24 h her haemoglobin
dropped to 8.1 and platelets to 106×10 3 /mm 3 . Liver func-
tion was mildly deranged: alkaline phosphatase 140 IU/l,
alanine aminotransferase 64 IU/l and bilirubin 23 μmol/l.
Coagulation was impaired with an international normal-
ised ratio of 1.3.
Blood cultures grew Listeria monocytogenes . Throat swab
cultured a heavy growth of Candida albicans .
HIV type 1 antibody was positive, HIV viral load (PCR,
Abbott Laboratories Ltd, Berkshire, UK) was 123 9303 cop-
ies/ml and CD4 count was 84.
Ultrasound of the abdomen revealed gross cholecystitis
with multiple medium sized stones and a thickened gall
bladder wall (13 mm). There was no common bile duct or
intrahepatic duct dilatation. There was hepatosplenomeg-
aly. The pancreas and kidneys were normal, and no ascites
or free fl uid was seen.
CT of the abdomen confi rmed the results of the ultra-
sound and did not reveal any collection that was amenable
to CT-guided drainage. ?-Human chorionic gonadotropin
test was negative.
The diagnosis was L monocytogenes septicaemia (listerio-
sis) and cholecystitis on a background of HIV infection. The
gall bladder was considered to be the source of sepsis.
Sepsis was initially treated with intravenous Tazocin 4.5 g
three times a day, which was changed after 30 h of treat-
ment following the blood culture results to a combination
of intravenous amoxicillin 2 g four times a day (14 days),
intravenous gentamicin 5 mg/kg/day (9 days) and oral met-
ronidazole 400 mg three times a day (10 days). The patient
was resuscitated with intravenous fl uids and intravenous
vitamin K 5 mg was given to normalise clotting.
Laparoscopic cholecystectomy performed 3 days after
admission removed a distended, thick walled gall bladder
that had some fl imsy adhesions and free peritoneal fl uid.
Unusual association of diseases/symptoms
A complicated case of cholecystitis, listeriosis and HIV/AIDS
L Maddocks, 1 P Khanna, 2 N Reay-Jones 3
1 Barnet and Chase Farm NHS Trust, Chase Farm Hospital, The Ridgeway, Enfi eld, Middlesex, UK ;
2 Pathology Department, East and North Hertfordshire NHS Trust, Lister Hospital, Stevenage, Hertfordshire, UK ;
3 Surgery Department, East and North Hertfordshire NHS Trust, Queen Elizabeth II Hospital, Howlands, Welwyn Garden City, Hertfordshire, UK
Correspondence to L Maddocks, email@example.com
A 37-year-old woman of Tanzanian origin presented with symptoms of cholecystitis, sepsis and oral candidiasis. Subsequent investigation
found listeriosis and HIV infection. Effective use of the appropriate antibiotics and surgical management to remove the source of sepsis lead
to a good recovery from the acute illness. The patient was subsequently transferred to a tertiary centre for specialist care of her underlying
chronic condition of HIV/AIDS. Her case demonstrates a previously unreported association of HIV, Listeria and cholecystitis.
BMJ Case Reports 2011; doi:10.1136/bcr.08.2010.3292
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OUTCOME AND FOLLOW-UP
This woman made a good postoperative recovery with
14 days of intensive care unit/high dependency unit care.
She was extubated on day 1 after her operation and was
quickly alert and oriented. Her infl ammatory markers rap-
idly normalised after surgery. Recovery was only compli-
cated by a persistent acidosis and hyperchloraemia which
corrected with supportive management.
Histology found a gall bladder specimen with a 6 mm
stone in the lumen and wall thickness of 2–3 mm. The
mucosa was irregular with focal superfi cial ulceration,
chronic mucosal infl ammation, muscle hyperplasia and
Rokitansky–Aschoff sinus formation, all consistent with
chronic cholecystitis and cholelithiasis.
Microbiological analysis of the gall bladder did not cul-
ture L monocytogenes from the sample.
Subsequent investigation for HIV associated infections
confi rmed cytomegalovirus (CMV) infection (CMV DNA
PCR 797 copies/ml) and ophthalmology found possible
early changes of CMV retinitis. Toxoplasma, hepatitis
viruses and syphilis were negative.
Given her CD4 count of 84/mm 3 , the patient was treated
with prophylactic cotrimoxazole 480 mg once daily and
oral antiretroviral therapy consisting of tenofavir diso-
proxil 245 mg once daily, emtricitabine 200 mg once daily
and efavirenz 600 mg once daily.
Having made a successful recovery from her cholecysti-
tis and listeriosis, this woman was transferred to a tertiary
referral centre for specialist care of her acquired immuno-
defi ciency syndrome.
L monocytogenes cholecystitis has been reported in two pre-
vious cases from Austria in 1986/1987, in both of which
the infection was localised to the gall bladder. 1 One earlier
case was reported in 1986. 2
HIV infection is well recognised as a factor predisposing
to listeriosis. Guerra et al 3 investigated all cases of listerio-
sis in HIV-infected individuals in Spain prior to 2004. They
found 21 reported cases and concluded that ”although
L monocytogenes infection is infrequent in HIV-infected
patients... clinicians should be alert to this possibility, since
even the severe clinical forms have a favourable prognosis
with proper treatment”.
A PubMed search for HIV/cholecystitis/ Listeria does not
fi nd any published articles linking the three conditions.
However, HIV infection is associated with both cholan-
giopathy and acalculous cholecystitis in the late stages of
A simple, common presentation such as cholecystitis
may have a rare aetiology.
Identifi cation of co-morbidities using simple tests (in
this case blood cultures) allows for effective, targeted
treatment of serious conditions.
Multidisciplinary management utilising diverse skill sets
facilitated optimal treatment of this complex case.
infection and when a low CD4 count has developed. 4 In
our case the fi ndings of calculi, only mildly elevated liver
function tests and a normal biliary tree do not support
Recent research into the pathogenesis of L monocytogenes
has begun to focus on the gastrointestinal phase of this food
borne bacteria. 5 In 2004 Hardy et al found good evidence of
extracellular L monocytogenes replication in the gall bladder
of mice. 6 In our case, L monocytogenes could not be cultured
from the excised gall bladder, which is not surprising as the
patient had received 4 days of intravenous antibiotics by
the time her gall bladder was removed and, additionally,
molecular methods of detection were not employed.
This case report presents a previously unreported
triad of HIV infection, listeriosis and cholecystitis. It is
also an example of a serious condition with high mortal-
ity (20–30% in high risk individuals) 7 being effectively
treated with prompt and appropriate surgical and medical
Competing interests None.
Patient consent Obtained.
1. Allerberger F, Langer B, Hirsch O, et al . Listeria monocytogenes cholecystitis .
Z Gastroenterol 1989 ; 27 : 145 – 7 .
2. Gordon S, Singer C . Listeria monocytogenes cholecystitis . J Infect Dis
1986 ; 154 : 918 – 19 .
3. Guerra J, Muinelo I, Perer-Simon MR, et al . Listeriosis in patients with human
immunodefi ciency virus infection in Spain. Three new cases and a literature
review. (Article in Spanish) . Enferm Infecc Microbiol Clin 2004 ; 22 : 18 – 21 .
4. Schiff ER, Sorrell MF, Maddrey WC . Schiff’s Diseases of the Liver . Vol 2 .
Tenth edition . Philadelphia, PA, USA : Lippincott Williams and Wilkins 2007 .
5. Gahan CGM, Hill C . A review: gastrointestinal phase of Listeria
monocytogenes infection . J Appl Microbiol 2005 ; 98 : 1345 – 53 .
6. Hardy J, Francis KP, DeBoer M, et al . Extracellular replication of Listeria
monocytogenes in the murine gall bladder . Science 2004 ; 303 : 851 – 3 .
7. Ramaswamy V, Cresence VM, Rejitha JS, et al . Listeria – review of
epidemiology and pathogenesis . J Microbiol Immunol Infect 2007 ; 40 : 4 – 13 .
BMJ Case Reports 2011; doi:10.1136/bcr.08.2010.3292
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