Trifascicular block and a raised Troponin 'T' in acute cholecystitis

A 76-year-old man, with an unremarkable past medical history and no cardiac risk factors, acutely developed right sided pleuritic and upper quadrant abdominal pain associated with dyspnoea. On examination, he had decreased air entry at the right base. There was localised peritonitis in the right upper quadrant and Murphy's sign was positive. Investigations demonstrated type 1 respiratory failure and an elevated Troponin T at 0.06 ng/ml with a normal eGFR. d-dimer was >0.12 g/dl, a neutrophilia was evident at 9 × 109/l and the CRP was 196 mg/l. A chest radiograph illustrated right basal atelectasis. An electrocardiogram (ECG) demonstrated a trifascicular block (right axis deviation, right bundle branch block with left posterior hemi block and first degree heart block) (Figure 1). A comparative ECG from 2005 was normal (Figure 2). He was empirically treated for a pulmonary embolism with secondary right basal atelectasis. However, a computed tomography pulmonary angiogram scan (Figure 3) confirmed acute cholecystitis and right lower lobe consolidation, but no pulmonary embolism. His pulmonary arterial and right heart dimensions were normal with no evidence of pulmonary hypertension or right ventricular dilatation. Blood cultures grew coliforms suggesting the acute cholecystitis was complicated by biliary sepsis.