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, firstname.lastname@example.org
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.