Unmasking lupus: acalculous cholecystitis presenting as the initial manifestation of systemic lupus erythematosus

Abstract

Acute acalculous cholecystitis (AAC) is an uncommon cause of gallbladder inflammation, typically occurring in critically ill patients. Its presentation as the initial manifestation of systemic lupus erythematosus (SLE) is exceedingly rare. We report the case of a 30-year-old female with hypothyroidism and remote history of pleural tuberculosis, who presented with acute right upper quadrant pain, fever, photosensitive rash, oral ulcers, and generalized edema. Imaging revealed gallbladder wall thickening with pericholecystic fluid in the absence of gallstones, consistent with AAC. Serological evaluation demonstrated strongly positive ANA and anti-dsDNA antibodies with hypocomplementemia, while renal biopsy confirmed Class II mesangial proliferative lupus nephritis. Additional findings included lupus pneumonitis, pleural and peritoneal serositis, and arthralgia, establishing a diagnosis of multisystem SLE. The patient responded favourably to corticosteroids, mycophenolate mofetil, and hydroxychloroquine, with resolution of systemic features and avoidance of surgical intervention. This case highlights AAC as a rare heralding manifestation of SLE and underscores the importance of considering autoimmune etiologies in atypical AAC presentations. Early recognition and prompt immunosuppressive therapy are crucial to prevent unnecessary cholecystectomy and irreversible organ damage.