we report a rare case of enteric perforation of acalculous gallbladder in a 14-year - old boy , who presented with acute abdomen and responded very well after immediate surgical intervention . a 14-year - old boy presented with history of diffuse abdominal pain since three days and not passing flatus and motion since 2 days . abdominal examination revealed abdominal distension , muscle guarding , generalized abdominal tenderness and sluggish bowel sounds . haemoglobin was 8  g / dl , platelets count was 96,000/l and wbc count was 1600/l ( neutrophil 64% , lymphocyte 28% ) . peripheral smear showed normocytic , normochromic red blood cells with mild anisocytosis , severe leukopenia and mild thrombocytopenia . an erect abdominal radiograph revealed multiple air - fluid levels and there was no free gas under the diaphragm . abdominal ultrasonography demonstrated hepatosplenomegaly and gross ascites with fine internal echoes , suggestive of perforation . peritoneal cavity was containing 2  l of bilious fluid and bowel loops were appeared to be normal . on further exploration , gallbladder appeared to be grossly inflamed and there was a single perforation of around 1  cm in size at the fundus ( figs . 1 and 2 ) . we looked carefully for gallstones in gallbladder , cystic duct and peritoneal cavity but not found . post - operatively , intra - venous ceftriaxone and gentamicin were administered for 7 days . there was an uneventful recovery and patient was discharged on 9th post - operative day . culture of bile and peritoneal fluid were positive for salmonella typhi and escherichia coli respectively . enteric fever is caused by salmonella typhi , s. paratyphi a , and rarely by s. paratyphi b and c. it is common in developing countries due to poor water quality and sanitation . it is an acute systemic disease consisting of fever , malaise , transient rash , hepatosplenomegaly , abdominal discomfort and pancytopenia . it is an intracellular infection involving the reticuloendothelial system , particularly bone marrow , liver and spleen . bone marrow examination may show marked phagocytosis of platelets , leukocytes , and red blood cells reported 2 cases of gallbladder perforation due to enteric fever in two boys aged 13 years and 16 years . our patient was from tropic and was having fever , abdominal discomfort , anaemia , leukopenia , hepatosplenomegaly and widal positivity , all suggestive of enteric infection . roslyn et al . observed that gallbladder perforation is more common in older age group . in elderly , perforation usually occurs in setting of cholelithiasis associated with obstruction leading to raised intra luminal pressure . perforation appeared to be result of compromised blood supply and least vascularised fundus is the most common site . in contrast , acalculous cholecystitis without obstruction is unlikely to result in perforation . in young patients , perforation is often associated with acute acalculous cholecystitis due to acute infections like pneumonia , viral influenza and enteric fever . perforation in such cases is likely to be result of intense inflammation coupled with acute infection and existence of an immuno - compromised state leading to uncontrolled infection and thrombosis of the blood vessels . our patient probably developed gallbladder perforation due to ischaemia of gallbladder wall due to acute intense inflammation . it thought to occur more frequently in the elderly due to the loss of visceral fat and elasticity with older age , thus permitting the gallbladder to hang freely . cholecystectomy is treatment of choice in such cases and provides good result . here , patient showed rapid recovery following cholecystectomy . in our case , laparoscopy was not performed due to unavailability of it in our emergency set - up . fluoroquinolones or ceftriaxone ( 12  g / day ) would be optimal choices in the treatment of such cases . in uncomplicated enteric fever , in complicated cases , antibiotics are given for 714 days depending on condition of patient . in our case , antibiotics were given for 7 days . our case is unusual because patient was a child , with no prior history suggestive of gallbladder disease , had no known medical co - morbidity and showed absence of gall stones on ultrasound and surgery . gallbladder perforation secondary to enteric fever requires a high degree of clinical suspicion , especially in this age group . in typhoid endemic region , it should be considered as a differential diagnosis in patient presenting with a history of prolonged fever and signs of peritonitis . early diagnosis and immediate surgical intervention are very important in reducing the morbidity and mortality associated with this condition . written informed consent was obtained from the patient 's guardian for publication of this case report and accompanying images . a copy of the written consent is available for review by the editor - in - chief of this journal on request . written informed consent was obtained from the patient 's guardian for publication of this case report and accompanying images . a copy of the written consent is available for review by the editor - in - chief of this journal on request .