Clinically Silent Presentation of Acalculous Gangrenous Cholecystitis: A Case Report

Acalculous gangrenous cholecystitis is a rare, life-threatening form of acute cholecystitis associated with significant morbidity and mortality. Neurological deficits may obscure early recognition of severe intra-abdominal pathology, contributing to delayed diagnosis and potentially worse clinical outcomes. We report a case of a 43-year-old male with recent intracerebral hemorrhage and residual right-sided hemiplegia who presented with high-grade fever and progressive clinical deterioration without prominent abdominal findings. Laboratory investigations demonstrated pronounced inflammatory changes accompanied by a predominantly cholestatic pattern of liver enzyme abnormalities. Urine culture was obtained during the diagnostic workup and the culture yielded extensively drug-resistant Klebsiella pneumoniae, likely reflecting healthcare-associated colonization rather than true infection. Abdominal imaging demonstrated findings suspicious for cholecystitis. Due to persistent worsening inflammatory markers despite empirical antimicrobial therapy, urgent laparoscopic intervention was undertaken. Intraoperative findings confirmed acalculous gangrenous cholecystitis complicated by purulent biliary peritonitis. Laparoscopic cholecystectomy with peritoneal lavage and drainage was successfully performed. The patient demonstrated rapid postoperative clinical improvement following definitive surgical source control. This case highlights the diagnostic challenge of clinically occult acalculous gangrenous cholecystitis and emphasizes that severe biliary infection may occur despite minimal abdominal findings. Particular vigilance is warranted in patients with neurological impairment, in whom residual neurological deficits may mask the progression of serious intra-abdominal pathology and contribute to delays in diagnosis and definitive treatment.