The Conundrum of MRSA Cholecystitis and Cholestatic Liver Enzyme Elevation

Document Type

Conference Proceeding

Publication Date

10-2024

Publication Title

American Journal of Gastroenterology

Abstract

Introduction: Methicillin-resistant Staphylococcus aureus (MRSA) is a common cause of healthcare-associated infections, presenting in diverse clinical contexts. Cholecystitis secondary to MRSA is a rare but documented finding. This case highlights the management of a complex patient presenting with MRSA bacteremia and cholecystitis. Case Description/Methods: A 69-year-old man presented with right upper quadrant pain for 5 days and sepsis with hypotension, lactic acidosis of 2.2 mmol/L, and elevated liver enzymes in a cholestatic pattern (alkaline phosphatase 799 U/L, aspartate aminotransferase 73 U/L, alanine aminotransferase 124 U/L). Initial management included fluid resuscitation and piperacillin-tazobactam. Blood cultures returned positive for MRSA, prompting the addition of vancomycin. Ultrasound and computed tomography scan revealed gallbladder distension with pericholecystic fluid concerning for cholecystitis. Cholecystectomy was deferred in favor of percutaneous cholecystectomy, which was completed on the third day of admission; purulent gallbladder aspirate revealed many MRSA on culture. Repeat blood cultures 2 days following drain placement revealed clearance of MRSA bacteremia. An Endoscopic Retrograde Cholangiopancreatography (ERCP) was completed on the seventh day of admission due to a continued cholestatic pattern of liver enzymes (alkaline phosphatase 567 U/L, aspartate aminotransferase 50 U/L, alanine aminotransferase 60 U/L), which revealed no biliary obstruction. A transthoracic echocardiogram did not reveal any vegetation. Given a history of esophageal rupture, a 4-week course of daptomycin was preferred over further esophageal instrumentation, and his liver enzymes trended down. Discussion: In this case, the high concentration of MRSA cultured from the gallbladder, rapid resolution of bacteremia following source control, and lack of other infectious sources suggest primary MRSA cholecystitis. Given the lack of biliary obstruction, the cholestatic pattern likely represented hepatic inflammation and bile stasis mediated through inflammatory cytokines or direct bacterial effects. This case emphasizes the need for thorough diagnostic evaluation, including imaging studies and culture-directed therapy, while highlighting the need for rapid, safe source control. The rarity of MRSA as a cause of cholecystitis necessitates clinical awareness in cases of suspected cholecystitis with severe systemic manifestations. This patient’s cholestatic liver enzyme pattern underscores the diverse hepatic responses to systemic infections and the importance of comprehensive diagnostic evaluation to guide treatment strategies (see Figure 1)

Volume

119

Issue

10S

First Page

S1798

Comments

American College of Gastroenterology Annual Scientific Meeting, October 25-30, 2024, Philadelphia, PA

DOI

10.14309/01.ajg.0001039596.19390.df

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