International Journal of Surgery Case Reports 87 (2021) 106471

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International Journal of Surgery Case Reports

journal homepage: www.elsevier.com/locate/ijscr

Case report

Isolated gallbladder tuberculosis in an 84-year old man: A rare case report

Murad Tarmohamed a, e, *, Alex Mremi b, e, Elifuraha Mkwizu d, e, Joel Paschal e, Adnan Sadiq c, e,
David Msuya a, e
a
Department of General Surgery, Kilimanjaro Christian Medical Centre, P.O. Box 3010, Moshi, Kilimanjaro, Tanzania
b
Department of Pathology, Kilimanjaro Christian Medical Centre, P.O. Box 3010, Moshi, Kilimanjaro, Tanzania
c
Department of Radiology, Kilimanjaro Christian Medical Centre, P.O. Box 3010, Moshi, Kilimanjaro, Tanzania
d
Department of Internal Medicine, Kilimanjaro Christian Medical Centre, P.O. Box 3010, Moshi, Kilimanjaro, Tanzania
e
Kilimanjaro Christian Medical University College, P.O. Box 2240, Moshi, Kilimanjaro, Tanzania

A R T I C L E I N F O A B S T R A C T

Keywords: Introduction: Isolated gallbladder tuberculosis is extremely rare even in endemic regions posing diagnostic
Case report challenges as the presentation mimics other gallbladder diseases such as cholecystitis and gallbladder carcinoma.
Gallbladder Preoperative suspicion index is negligible with most cases being diagnosed postoperatively from resected
Tuberculosis
specimen.
Case presentation: Herein, we report an elderly man who presented with jaundice, and was clinically diagnosed
with gallbladder carcinoma.
Discussion: Histopathology of resected gallbladder revealed gallbladder tuberculosis. No features of tuberculous
infection were found elsewhere.
Conclusion: Healthcare providers should have a high index of suspicion particularly for patients in endemic areas
presenting with cholecystitis to obtain a pre-operative diagnosis.

1. Introduction features of obstructive jaundice and GB perforation on CT scan, and

intra-operative appearance of GB carcinoma in line with the SCARE
Over the last ten years the world has witnessed a trend towards 2020 criteria [9].
increasing numbers of people who have been infected with tuberculous
(TB) infection [1]. Majority of these cases are found in middle and low 2. Case presentation
income countries like Tanzania. Extra-pulmonary tuberculosis (EPTB)
accounts for roughly 15% of TB cases among immunocompetent hosts An 84-year-old man was referred to us from a regional hospital with
[2]. Some of the EPTB clinical variants include TB lymphadenitis, two weeks' history of abdominal pain associated with non-projectile
peritonitis, pericarditis, pleural TB, and Pott's disease. Gallbladder coffee ground vomiting, melena and weight loss. No history of abdom­
tuberculosis (GT) remains a well-recognized rare infectious disease since inal distention or constipation. No history of fever was reported. At the
its first description in 1870 by Gaucher [3]. In endemic regions, tuber­ regional hospital, an abdominal ultrasound was suggestive of intra­
culosis often remains part of differential diagnosis in managing patients hepatic mass. Serologies for hepatitis A, B and C, and HIV were negative.
with disease of any organ system [4]. The gallbladder (GB) is relatively The patient was referred to us for endoscopy and CT scan of the
immune to tubercular infection possibly due to its thick wall and natural abdomen. Initial examination at our centre revealed a weak and
resistance conferred by bile [5]. The lack of pathognomonic presenta­ emaciated patient. He was pale, icteric and had bilateral lower limb
tion coupled with possibly a high incidence of TB in regions endemic for edema. The patient admitted to moderately consume alcohol in the past.
GB carcinoma makes preoperative diagnosis unlikely [6]. The diagnosis He was not addicted to any prescription or recreational drug. There is no
is often discovered after histological evaluation of GB resected for sus­ history of TB infection or TB contact. There was no significant personal
pected malignancy [7]. By 2010 around 120 cases had been published or family history of chronic diseases. The patient denied being on any
[8]. Here, we report a case of an elderly man who presented with medications. His vital signs were within normal range. The abdomen

* Corresponding author at: Department of General Surgery, Kilimanjaro Christian Medical Centre, PO. Box 3010, Moshi, Kilimanjaro, Tanzania.
E-mail address: murad.tarmohamed@kcmc.ac.tz (M. Tarmohamed).

https://doi.org/10.1016/j.ijscr.2021.106471
Received 23 August 2021; Received in revised form 30 September 2021; Accepted 3 October 2021
Available online 6 October 2021
2210-2612/© 2021 The Authors. Published by Elsevier Ltd on behalf of IJS Publishing Group Ltd. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).
M. Tarmohamed et al. International Journal of Surgery Case Reports 87 (2021) 106471

B C

Fig. 1. Axial (A), coronal (B) and sagittal (C) CT images of the abdomen displaying asymmetrical thickening of the gallbladder with contained perforation along its
anterior margins. Site of perforation demonstrated by arrow head.

was of normal contour, soft and tender at the right upper quadrant being intrahepatic mass with obstructive component.
(RUQ). No enlarged liver or spleen was appreciated. Normal bowel The patient basic blood work and serum chemistries were as follows:
sounds were heard. Other systems were essentially normal. The patient Erythrocyte Sedimentation Rate (ESR) of 110 mm/h, hemoglobin of 6.9
was admitted to the medical ward for evaluation, the working diagnosis g/dL, direct and total bilirubin of 34.83 μmol/L and 108 μmol/L

Fig. 2. Histopathology of the gallbladder specimen highlighting necrotizing inflammation with foamy histiocytes; H&E staining 40× original magnification (A); and
presence of horse-shoe shaped multinucleated giant cells; H&E staining 100× original magnification (B).

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M. Tarmohamed et al. International Journal of Surgery Case Reports 87 (2021) 106471

respectively, alanine and aspartate aminotransferase (ALT and AST) Abbreviations

were 44 I/U and 81 I/U respectively. CT scan abdomen (Fig. 1) showed
mildly dilated intrahepatic biliary ducts, common hepatic duct (CHD) CBD common bile duct
and common bile duct (CBD) measuring 1.3 cm in caliber with abrupt CHD common hepatic duct
cut off at the ampulla of Vater suggestive of ampullary vs. peri- EPTB extra pulmonary tuberculosis
ampullary obstruction. A dilated GB with asymmetrical wall thick­ GB gallbladder
ening and contained GB wall perforation was noted. No evidence of GT gallbladder tuberculosis
calculus. These findings were suggestive of mild biliary obstruction RUQ right upper quadrant
secondary to ampullary obstruction with contained perforated acalculus TB tuberculosis
cholecystitis.
A presumptive diagnosis of GB/cholangio-carcinoma was rendered Funding
and the patient was transferred to the surgical unit and optimized for
surgery. Intraoperatively, there was gross inflammation of the GB and No funding received towards this paper.
surrounding areas in the RUQ. Necrotic GB fundus and body with gross
edema of the walls, the neck, the cystic duct and rest of the biliary tree. Ethical approval
No obvious mass was palpable at the head of pancreas. Liver, stomach
and colon were grossly normal. A subtotal cholecystectomy sparring the Ethical approval not required.
neck of the GB was done. Lack of intraoperative cholangiogram and
choledochoscopy necessitated insertion of smallest bougie in the CHD Consent
and CBD which was unsuccessful due to gross edema however, bile flow
from within GB neck was noted. Reconstruction was done by Roux-en-Y Written informed consent was obtained from the patient for publi­
cholecystojejunostomy. The excised GB tissue which was submitted for cation of this case report and accompanying images. A copy of the
histological studies showed necrotizing inflammation with dense in­ written consent is available for review by the Editor-in-Chief of this
flammatory cells infiltration including foamy histiocytes, plasma cells journal on request.
and Langerhans multinucleated giant cells (Fig. 2A). The Ziehl-Nelsen
special stain for acid-fast bacillus was positive. This morphology fa­ Authors' contributions
vors TB infection (Fig. 2B).
In the post-operative period, the patient was initiated on isoniazid, MT and JP conceptualized and drafted the initial manuscript.
rifampicin, pyrazinamide and ethambutol. The patient had caseous MT and DM were lead surgeons.
effluent per abdominal drain which decreased over time and eventually EM involved in initial patient care.
stopped after initiation of anti-TB drugs. The patient displayed signifi­ AM performed histopathological analysis.
cant recovery both from the surgery and the primary disease when MT, EM and AM were responsible for final manuscript version.
reviewed six weeks after surgery. AS reviewed and reported the radiographs.
All authors have read and approved the final script.
3. Discussion
Research registration
Hepatobiliary TB is a rare occurrence of abdominal TB accounting for
about 1%. Even rarer, is the occurrence of isolated GT rendering it least N/A.
susceptible to diagnosis.
While patients infected with GT may present with a combination of Guarantor
abdominal pain, jaundice, weight loss and vomiting - symptoms which
overlap or may be clinically misinterpreted as cholecystitis, biliary Murad Tarmohamed (MT).
obstruction or carcinomas; right hypochondriac pain and abdominal
mass may stand out as key findings in a GT patient. In stark contrast to Declaration of competing interest
this case, around 70% of GT cases are accompanied by gallstones [10].
To add to the diagnostic dilemma, Xu et al. described micronodular No conflict of interest.
lesion of the GB wall, a thickened wall and a GB mass as the commonest
findings on CT scan in majority of GT cases [8] however, these radio­ Acknowledgement
logical findings are not pathognomonic to GT and may also be seen in
other chronic and malignant affections of the biliary tree. The diagnostic We are grateful to the patient for letting us use his case to report this
challenge to CT scan interpretation can be explained by the chronic rare condition.
inflammation that is common to all these disease entities.
The usually low suspicion index of GT in clinical settings renders the
Provenance and peer review
availability of specific tests for TB inutile to the accurate preoperative
diagnosis. Our report highlights the multivariable and non-specific
Not commissioned, externally peer-reviewed.
clinical presentations of GT. Healthcare providers should have a high
index of suspicion particularly for patients in endemic areas presenting
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