LAUSR

A 54-year-old male sought medical care with complaint of mild right hypochondrium abdominal pain lasting for 7 days with concomitant 3-day intermittent fever and 1-day nonpruritic maculopapular rash on torso and arms. One week before the onset of symptoms, the individual presented with aqueous diarrhea. Previous medical history included diabetes, rheumatoid arthritis, and large granular lymphocytic leukemia, for which he was treated with methotrexate, neutropenia, and past episodes of intermittent unconjugated hyperbilirubinemia attributed to Gilbert’s syndrome (homozygous for the thymine-adenine [TA]7TAA-allele). The patient was found to be dehydrated and febrile (38.38C). He appeared to have mild abdominal discomfort, with a positive rebound tenderness sign but a negative Murphy’s sign. Laboratory workup is shown in Table 1. Ultrasound and computed tomography findings were compatible with AAC (Fig. 1A,B). A comprehensive screening for infectious disease was conducted with negative results, but serum positive by polymerase chain reaction (RT-PCR) for ZIKV. Similarly, tests confirmed ZIKV in bile and gallbladder tissue by RT-PCR, with a 100% homology to a ZIKV sequence (see Supplementary Materials). The patient received empiric intravenous antibiotic therapy, including ceftriaxone (2 g/day) and metronidazole (2.25 g/day). Nonetheless, the patient’s general condition continued to deteriorate, and thus a laparoscopic cholecystectomy was performed. No Murphy’s sign developed during disease course. Surgical exploration (lasting 290 minutes) was difficult because of numerous adhesions and pericholecystic plastron. In addition, the patient was hyperthermic and hypotensive. Fluids and noradrenaline were administered and vital parameters stabilized. Intraoperative findings comprised an enlarged gallbladder with thickened walls and viscous bile inside with no calculi. Gallbladder histology revealed large portions of organizing