What are the clinical features of gallbladder aspergillosis?

Clinical Features of Gallbladder Aspergillosis

Gallbladder aspergillosis is a rare manifestation of invasive aspergillosis that typically presents with abdominal pain and may lead to potentially fatal complications including hemorrhage, perforation, obstruction, and infarction if not promptly diagnosed and treated.

Epidemiology and Risk Factors

• Gallbladder aspergillosis occurs primarily in immunocompromised patients, similar to other forms of invasive aspergillosis 1
• Major risk factors include:
  • Organ transplantation (seen in approximately 34% of intestinal aspergillosis cases) 1
  • Prolonged neutropenia 2
  • Hematopoietic stem cell transplantation 2
  • Chemotherapy for hematologic malignancies 3
  • Advanced AIDS 4
  • Chronic granulomatous disease 4

Clinical Presentation

• Abdominal pain is the most common presenting symptom (38% of intestinal aspergillosis cases) 1
• Diarrhea is reported in approximately 21% of cases 1
• Fever and other systemic symptoms may be present, especially in disseminated infection 5
• Gallbladder aspergillosis may present as part of disseminated invasive aspergillosis or as isolated organ involvement 3
• Patients may present with signs of biliary obstruction when the infection involves the biliary tract 5
• Abdominal distension may occur in some cases 1

Diagnostic Findings

• Mean time to diagnosis is approximately 8.6 days, indicating the diagnostic challenge 1
• Diagnosis often requires:
  • Exploratory laparotomy (63% of intestinal aspergillosis cases) 1
  • Endoscopic procedures (13% of cases) 1
• Imaging findings on CT may include:
  • Multiple low-attenuating lesions presenting as abscesses 3
  • Evidence of vascular thrombosis or pseudoaneurysm leading to organ infarction 3
  • Diffuse or nodular infiltration of surrounding tissues 3
• Laboratory findings may include:
  • Positive galactomannan antigen detection in body fluids 2
  • Positive fungal culture from tissue or fluid samples 5
  • Positive PCR for Aspergillus DNA 2

Patterns of Infection

• Gallbladder aspergillosis may occur as:
  • Primary infection (66% of intestinal aspergillosis cases) 1
  • Secondary to systemic aspergillosis (34% of cases) 1
• The infection may extend to involve:
  • Biliary tract with potential obstruction 5
  • Surrounding hepatic tissue 5
  • Peritoneum in cases of perforation 5

Complications

• Potential complications include:
  • Hemorrhage from ulcerative lesions 5
  • Perforation of the gallbladder 5
  • Biliary obstruction 5
  • Tissue infarction due to angioinvasive properties of Aspergillus 5, 3
  • Extension to surrounding tissues including liver and peritoneum 5, 3

Management Approach

• Combined medical and surgical management is typically required 5
• Surgical intervention is often necessary to prevent complications 1
• Voriconazole is the recommended first-line antifungal therapy 5
• Alternative antifungal options include:
  • Lipid formulations of amphotericin B 5
  • Posaconazole as salvage therapy 5
• Mortality rate is high (39% for intestinal aspergillosis) despite treatment 1
• Surgical management combined with antifungal therapy shows better survival rates (63%) compared to antifungal therapy alone (46%) 1

Prognosis

• Gallbladder aspergillosis, like other forms of invasive aspergillosis, is associated with high morbidity and mortality 1
• Early diagnosis and aggressive treatment are essential to improve outcomes 2
• Patients who undergo combined surgical and medical treatment have better survival rates than those treated with antifungal therapy alone 1