EMPYSEMATOUS CYSTITIS: An unusual cause of haematuria.

By Dr Olusegun Oduyoye; Specialty registrar at BGH, Dr Lucas Ferrando; Consultant Radiologist at BGH Dr Carol Norris; Consultant Geriatrician at BGH.

ABSTRACT

Emphysematous cystitis is a rare disease entity caused by gas forming bacteria. Its clinical presentation can be non-specific; hence a high index of suspicion is needed in susceptible population. We report the case of a 93yr old male who presented with haematuria, fever and chills who was found to have Emphysematous cystitis.

Key words: Emphysematous cystitis and haematuria

INTRODUCTION Emphysematous cystitis is an uncommon infection of bladder wall formed by gas forming organisms. It’s presentation varies and can be atypical, hence the need for a high index of suspicion in high-risk groups. We report a case of a male nonagenarian with long-term catheter that presented with haematuria, fever and chills and was found to have Escherichia coli emphysematous cystitis that was treated with antibiotics.

CASE REPORT

93 yr old male residential home resident who presented with haematuria, fever and rigor of few days duration. He has extensive co morbidities, which includes cerebrovascular accident, atrial fibrillation [not warfarinized], and benign prostatic hyperplasia on long term catheter, chronic kidney disease, abdominal aortic aneurysm, heart failure and cognitive impairment. His medications include paracetamol, aspirin, sando-k, bisoprolol, finasteride, folic acid, furosemide, nitrazepam, tamsulosin, movicol and bisacodyl. On physical examination, he was confused and pyrexic with temperature of 39.4. His cardiovascular exam revealed pulse rate of 110 bpm with an irregularly irregular and low systolic blood pressure of 76mmHg.His chest was clinically clear except for tachypnoea. His abdomen was soft and non-tender. His full blood count showed a leucoytosis of 16,200cells/mm3, [CRP] 100mg/dl, and lactate 2.6. His coagulation screen was normal with a PT 12.6. His urine culture grew Escherichia coli. His renal function was more of an acute on chronic picture with an eGFR 29, urea 17.8mmol/l, creatinine of 297umol/L, potassium 4.9mmol/l, sodium 136mmol/l and bicarbonate 25. The computerized tomogram of his pelvis showed pockets of air within the wall of his bladder consistent with emphysematous cystitis.

Figure1: Transverse view shows air within the bladder wall consistent with emphysematous cystitis.

Figure 2: CT Pelvis: sagittal view of the bladder wall showing pockets of air within bladder wall.

He was empirically commenced on intravenous ciprofloxacin, metronidazole and gentamicin after discussion with the microbiologist. His haematuria resolved with appropriate bladder drainage.

DISCUSSION

Emphysematous cystitis is characterized by pockets of gas in the bladder wall caused by organisms like Escherichia coli [commonest cause][1], Klebsiella pneumonia and enterobacter aerogenes. It is thought that gas collections are carbon dioxide produced by fermentation of glucose by these organisms infecting the bladder [2]. Emphysematous cystitis is an uncommon condition. It requires a high index of suspicion in susceptible population. These are patients with long term catheter like our patient, diabetics, immunosuppressed patient, patients with bladder outlet obstruction, neutropenic bladder, and chronic urinary tract obstruction. Symptomatology of patients varies and is inconclusive [3]. This could include non- specific clinical features like haematuria [in our patient], pneumaturia [which is highly suggestive], dysuria, fever, and abdominal pain and in extreme cases sepsis like in our patient. The radiological finding in emphysematous cystitis includes small gas filled vesicles in mucosa. These can coalesce to form a thin zone of air outlining the bladder. Unlike our patient, blebs in the bladder wall can rupture to produce pneumaturia. Emphysematous cystitis usually responds to treatment with appropriate parenteral antibiotics and good drainage.

CONCLUSION

Emphysematous cystitis is a rare type of the genitourinary tract infection with non- specific symptoms. Hence not often diagnosed by routine or systematic approach. Physicians should have high index of suspicion in high-risk groups and tailor their radiological investigation accordingly. It should also be considered as a differential haematuria in high-risk groups.

REFERRENCES.

  1. Bailey H. Cystitis emphysematosa: 19 cases with intraluminal and interstitial collection of gas. Am J Roentgenol Radium Ther Nucl Med. 1961; 86:850-862.
  2. Quint HJ, Drach GW, Rappaport WD, Hoffman CJ. Emphysematous cystitis: a review of the spectrum of disease. J Urol 1992; 147: 134-137
  3. Weddle J, Brunton B, Rittenhouse DR. An unusual presentation of emphysematous cystitis. Am J Emerg Med. 1998; 16:664-6. Doi: 10.1016/S0735-6757 (98) 90170-X