Hindawi Publishing Corporation Case Reports in Medicine Volume 2013, Article ID 418014, 4 pages http://dx.doi.org/10.1155/2013/418014 Case Report Leukocytosis of Unknown Origin: Gangrenous Cholecystitis Amara Jyothi Nidimusili, 1 M. Chadi Alraies, 2 Naseem Eisa, 3 Abdul Hamid Alraiyes, 4 and Khaldoon Shaheen 2 1 Department of Medicine, Trinitas Regional Medical Center, Seton Hall University Health Sciences, Elizabeth, NJ 07202, USA 2 Department of Hospital Medicine, Institute of Medicine, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland Clinic, Cleveland, OH 44195, USA 3 Department of Hospital Medicine, Institute of Medicine, Cleveland Clinic, Cleveland, OH 44195, USA 4 Department of Pulmonary, Critical Care and Environmental Medicine, Tulane University Health Sciences Center, New Orleans, LA 70112, USA Correspondence should be addressed to Khaldoon Shaheen; khaldoonshaheen@yahoo.com Received 26 January 2013; Revised 23 February 2013; Accepted 11 March 2013 Academic Editor: Gianfranco D. Alpini Copyright © 2013 Amara Jyothi Nidimusili et al. his is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. here have been case reports where patients admitted with acute cholecystitis, who were managed conservatively, had subsequently developed GC (gangrenous cholecystitis). he current case is unique, since our patient denied any prior episodes of abdominal pain and the only tip of was leukocytosis. A high index of suspicion is essential for the early diagnosis and treatment of GC. GC has a mortality rate of up to 22% and a complication rate of 16–25%. Complications associated with GC include perforation, which has been reported to occur in as many as 10% of cases of acute cholecystitis. he radiological investigations may not be conclusive. Ultra- sonography usually serves as the irst-line imaging modality for the evaluation of patients with clinically suspected acute cholecys- titis. However, CT can play an important role in the evaluation of these patients if sonography is inconclusive. here is a need for an early (if not urgent) surgical intervention in acute cholecystitis (whether laparoscopic or open surgery) in order to decrease the time elapsed from the start of symptoms to admission and treatment. 1. Introduction Gangrenous cholecystitis is one of the most severe forms of gallbladder inlammation, and accounts for minority of all patients with acute cholecystitis. It is the result of marked distension of the gallbladder causing increased tension in the gallbladder wall. Associated inlammation leads to ischemic necrosis of the wall. We have an atypical and unique presen- tation of a patient with painless gangrenous cholecystitis. 2. The Case A 66-year-old obese man with history of diabetes mellitus and hypertension was admitted to the hospital for atypical let-sided chest pain of several hours duration worsened by movement and relieved with nitroglycerin. Cardiac workup was negative and chest pain subsequently resolved. On pre- sentation, he denied any abdominal pain, nausea, vomiting, fever, or chills. Physical examination was notable for heart rate of 110/minute, but other systemic examination was unre- markable. Initial workup showed WBC of 17,400/mm 3 with 13% bands; aspartate aminotransferase (AST) 6 u/L; alanine aminotransferase (ALT) 23 u/L; alkaline phosphatase 80 u/L, total bilirubin was 0.9 mg/dL, and gamma-glutamyl trans- peptidase (GGT) 55 U/L. During the hospital stay, leukocy- tosis persisted, with no possible source of infection had been identiied. On day 3, blood cultures came back positive for methicillin-resistant Staphylococcus epidermidis (MRSE) and Enterobacter sakazaki. He was started on IV vancomycin and meropenem. Initially, transthoracic echocardiogram was negative with no evidence of vegetations. Abdominal ultra- sound was done which showed multiple gallstones with nor- mal sized gallbladder, with no wall thickening or perichole- cystic luid. Hepatobiliary iminodiacetic acid (HIDA) scan