Acute Acalculous Cholecystitis in a Patient With COVID-19 and a LVAD

To the Editor:

We read with great interest the case report by Dr Singh and colleagues describing a case of complicated severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in a patient with a left ventricular assist device (LVAD).¹ They reported the patient's clinical course was complicated by septic shock in the setting of Escherichia coli and Lactobacillus species bacteremia, as well as acute acalculous cholecystitis (AAC) with the requirement for percutaneous cholecystectomy. However, in patients with LVAD, understanding the etiology of AAC primarily owing to SARS-CoV-2 may have significant clinical implications.

The cause of AAC that required a percutaneous cholecystostomy tube may be related to septic shock. Still, consideration should be given to alternative etiologies. Although AAC is a well-known occurrence in critically ill patients, its pathogenesis is thought to be due to gallbladder ischemia or bile stasis. It is commonly associated with shock, sepsis, and immunocompromised state.² Viral illnesses, including human immunodeficiency virus and hepatitis B virus, have been implicated in AAC.² SARS-CoV-2 has been associated with vascular inflammation, possibly promoting ischemic gallbladder changes independent of the development of shock.³ Finally, SARS-CoV-2 cellular entry is mediated by the angiotensin-converting enzyme 2 receptor, which expresses in relatively high amounts in the liver and gallbladder, as well as in vascular endothelium.^{4 , 5} Patients with SARS-CoV-2 infection may be at increased risk not only from ischemic changes to the gallbladder because of a critical illness, but also from direct viral effects on the vascular endothelium and infection to the biliary tissue itself.

Therefore, it is crucial to learn if any studies on the biliary aspirates were performed, including bile coronavirus disease-2019 (COVID-19) reverse transcriptase-polymerase chain reaction and bile culture, to confirm the presence of SARS-CoV-2 or coinfection with bacteria, respectively. It is even possible that the gallbladder endothelium may be a potential reservoir for viral infection, given the high level of expression of angiotensin-converting enzyme receptors.⁴ Follow-up bile testing if the patient continues to have percutaneous biliary drainage or gallbladder imaging may support COVID-19 recovery from an AAC standpoint.

Overall, clinicians treating patients with SARS-CoV-2 in the setting of LVAD with their multiple comorbidities should maintain a high clinical suspicion for the development of AAC. If the gallbladder is harboring prolonged viral replication, this may have clinical consequences, especially in patients with an LVAD being considered for a transplant. Current Centers for Disease Control and Prevention recommendations are for 2 consecutive nasopharyngeal reverse transcriptase-polymerase chain reaction test negatives (test-based strategy) to confirm COVID-19 disease recovery. Perhaps additional testing (including bile testing) or imaging should be done first in patients with LVAD and AAC to confirm recovery, especially before transplantation.

Declaration of Competing Interest

None.