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Paper text:
xanthogranulomatous cholecystitis ( xgc ) is an unusual form of cholecystitis that is accompanied by xanthomatous histiocytes , chronic inflammatory cells , and fibrosis , with varying degrees of involvement of one or all of the layers of the gallbladder wall .
xgc is most frequently observed in elderly women aged 50 - 70 years and is very rare in children .
a 2-month - old boy presented with a right upper abdominal palpable mass 3 days previously . he was born weighing 2,960 g at the 38th gestational week and no significant event occurred in the gestational period .
he had no previous medical problem and appeared well - developed and well - nourished . on physical examination , the mass in the right upper quadrant was firm and palpable , and the patient did not show any pain or tenderness .
laboratory findings showed the white blood cell count was 35,350/ml with 71% neutrophils , serum c - reactive protein level was elevated at 5.36 mg / dl ( normal , 0 to 0.5 mg / dl ) and serum alpha fetoprotein level was 1,316.41 ng / ml .
there was no evidence of hepatitis b virus , hepatitis c virus , cytomegalovirus or epstein - barr virus .
an ultrasonographic scan revealed a 4.5 cm  4.5 cm  4.7 cm heterogeneous hypoechoic mass with a lobulated contour at the gallbladder fossa ( fig .
the mass was suspected of having anterior subcapsular extension , and neither the gallbladder nor cholelithiasis were visible .
abdominal magnetic resonance imaging ( mri ) suggested a probable extrahepatic lesion , 5.3 cm  4.2 cm  3.4 cm in size and lobulated , involving the inferior aspect of s4 and s5 of the liver and anterior abdominal wall ( fig .
the gallbladder was not depicted on mri . under the impression that the mass might be a hepatoblastoma ,
were aspirated and these findings caused us to change our impression and diagnose liver abscess .
we used intravenous antibiotics for 11 days but there was no improvement of the lesion . on exploration ,
the gallbladder was severely inflamed with spreading of granulation to the liver , ascending colon and abdominal wall .
cholecystectomy with liver wedge resection and curettage of inflammatory tissue at the abdominal wall were performed .
pathologic examination showed xgc with abscess formation and chronic active inflammation with fibrosis in the liver bed ( fig .
he was planned to be undergone abdominal sonography after 6 months for follow - up with the potential possible malignant change .
xgc was first described by christensen and ishak   in 1970 , and named by mccoy et al .   in 1976 .
the exact cause of xgc is not proven , but according to the commonly accepted hypothesis , this disease starts with obstruction and acute inflammation of the gallbladder . over 80% of patients with xgc had gallstones that were estimated to be related to the onset of the disease . when the gallstones or some other factor obstruct the gallbladder and cause acute inflammation
, bile enters the stroma through the aschoff - rotitansky sinus or inflamed mucosa of gallbladder .
then histiocytes take up and ingest the bile and turn into xanthoma cells that lead to xgc .
clinically , xgc presents as acute or chronic cholecystitis , but biliary colicky pain is not common .
xgc is accompanied by severe inflammation and fibrosis that lead to tumor - like thickening of the wall and may form an adhesion with the connective tissue of neighboring organs of the gallbladder such as liver , small intestine , colon , and stomach .
adhesions to the abdominal wall are also seen and a case with a fistula to the skin has been reported .
these conditions make preoperative diagnosis difficult and sometimes raise suspicion of the presence of a tumorous condition such as advanced gallbladder cancer .
this case also showed severe adhesion with the liver , ascending colon and abdominal wall , and these findings led to the erroneous diagnosis of hepatoblastoma or other tumorous condition .
cholecystectomy is considered to be the treatment of choice , because xgc is usually confined to the gallbladder .
but in cases with extensive involvement of the surrounding organs , some authors recommend resection of all affected tissue .
intraoperative frozen - section investigation has been suggested as being necessary in diagnosing accompanying gallbladder carcinoma .
only a few cases of xgc in childhood have been reported   and very few cases in infancy   in the english literature .
xanthogranulomatous cholecystitis ( xgc ) is a rare form of chronic cholecystitis that is accompanied by xanthomatous histiocytes and chronic inflammation . a 2-month - old boy presented with a right upper abdominal palpable mass . 
 cholecystectomy with liver wedge resection was done , under the impression that the mass might be a hepatic tumor or liver abscess . 
 pathologic examination showed xgc with abscess formation . 
 most cases of xgc were observed in adult and only a few cases were reported in children . 
 we describe a very rare case of xgc in infancy .