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Clostridial cystitis emphysematosa
CLOSTRIDIAL
CYSTITIS EMPHYSEMATOSA*
JON S. WAYLAND,
M.D.
MARK D. KIVIAT,
M.D.
From the Department of Urology, Harbor-view Medical and University of Washington, Seattle, Washington
Center,
ABSTRACT - Two cases of cystitis emphysematosa with clostridial bacteremia are presented, and the potetitial importance of anaerobic organisms in producing this condition is emphasized.
Infection associated with interstitial gas production brings to mind anaerobic infections except in the urinary tract where the very existence of anaerobic infection remains in doubt. Cystitis emphysematosa is an uncommon affliction characterized by gas within the wall and the lumen of the bladder. The condition is seen most commonly in patients with hyperglycemia, the organism recovered from the urine usually being Escherichia coli or Enterobacter aerogenes. Less commonly, proteus, Staphylococcus aureus, streptococci, nocardia, or yeast are isolated from the urine. The following case reports provide evidence that anaerobes of the genus Clostridium may play a role in the causation of cystitis emphysematosa. Case Reports Case 1 An eighty-year-old man had nausea, vomiting, and mental confusion. He was a known diabetic. On physical examination, his vital signs were normal, chest was clear, and there was suprapubic tenderness. All laboratory data were normal except for blood sugar of 165 mg. per 100 ml., and urinalysis revealing glycosuria, ketonuria, and 10 to 15 white blood cells per high-power field. Aerobic urine culture was sterile. Blood culture drawn during a fever spike following catheterization for urinary retention recovered Clostridium welchii. An emphysematous ring was noted about a large bladder diverticulum on excretory urogram (Fig. 1). On postmortem examination, no hepatic or biliary abnormalities were disclosed which might have explained the clostridial sepsis.
*Supported
UHoLoC:I;
in part by Urology
/
XO\‘E.MBEH
1Y74
/
Special Fund.
VOLUME
IV, NUMBER
5
Case 2 A sixty-two-year-old woman was admitted with jaundice, hyperglycemia, and urinary retention. Her temperature was 99.4” F., the remainder of the vital signs being entirely normal. There was no hepatosplenomegaly. A roentgenogram revealed an emphysematous ring around the bladder (Fig. 2). Aerobic culture of the urine was sterile, while C. perfringens was isolated from the blood. The white blood cell count was 17,200, and urinalysis documented 4 to 20 white blood cells per high-power field. A thorough evaluation of the gastrointestinal tract, including liver scan, intravenous cholangiogram, upper gastrointestinal series, and barium enema failed to reveal any abnormality. The patient responded to 12 million units of penicillin daily for ten days; but after the antibiotic was discontinued, clostridia were again recovered from her blood. Intravenous cephalosporin finally proved effective. Subsequently insulin was required to control her diabetes. Comment These 2 cases illustrating cystitis emphysematosa with recovery of clostridia on blood culture and no organism from the aerobic urine culture constitute evidence that anaerobic organisms may have clinical importance. Burnes’ first implicated clostridia as a cause of cystitis emphysematosa in 1943; however, various authors have documented the recovery of anaerobes from urine of patients, the majority of which were asymptomatic. On reviewing the literature on anaerobic infections of the urinary tract, Finegold et al. ’ found 1 case of cystitis and 3 cases of pyelonephritis from which C. perfringens were isolated. Headington and Beyerlein3 isolated 195 anaerobes from 15,250 urine
so1
ring; (B) cystogram demonstrating diverticulum FIGURE 1. (A) Plain x-ray film ofpelvis showing- emphysematous .outlined by gas on plain film. - . specimens, clostridia representing 57 of the 195 isolates. Only 7 of the 195 patients were symptomatic. Similarly, Bittner et al. 4 found clostridia in only 1 of 400 urine cultures, and Kuklinca and Gavan5 found 1 patient in 200, a diabetic, positive for clostridia. Alling et ~1.~ on the other hand, recovered clostridia from 1 of 44 cultures in a group of incontinent geriatric patients. Perhaps the best documented case that clostridia may produce symptoms of cystitis is the report of Lykkegard-Nielsen and Laursen.’ They consistently isolated clostridia in multiple urine specimens until their patient became asymptomatic. The low but consistent incidence of anaerobic isolates from the urine raises the questions of how and where the organisms attain their ecologic niche. Clostridia are anaerobic or microaerophilic. The tolerance to oxygen varies with the species; for example, C. tetani will not form surface colonies if the air pressure exceeds 4.5 mm. Hg, while C. perfringens will tolerate up to 90 mm. Hg. In this regard, the presence of a re-
FIGURE 2. Plainfilm of abdomen showing huge bladder with gas in wall.
ducing sugar, 0.2 to 1 per cent glucose or a more efficient reductant such as cysteine, may well produce the reduced conditions necessary for the most fastidious of anaerobes. Glycosuria was a salient feature of both cases presented here. A second mechanism may also be operative. Little information is available regarding urinary oxygen tension, and published reports document wide variation in urinary ~02, a range of 4 to 70 mm. Hg.s In the case of retention and its associated distention of the bladder, the perfusion of the bladder may well be compromised, in which event the urothelium may further deplete the urinary pO2 and promote the growth of anaerobes. Seattle,
Washington 98195 (DR. KIVIAT)
References 1. BURNS,R. A.: Cystitis emphysematosa: a case report, J. Urol. 49: 808 (1943). 2. FINEGOLD,S. M., MILLER, L. G., MERRILL, S. L., and POSNICK,D. J.: Significance of anaerobic and capnophilic bacteria isolated from the urinary tract, in Kass, E. J.: Progress in Pyelonephritis, Philadelphia, F. A. Davis Co., 1965, p. 159. 3. HEADINGTON, J. T., and BEYERLEIN, B.: Anaerobic bacteria in routine urine culture, J. Clin. Pathol. 19: 573 (1966). 4. BITTNER, J., et al. : Incidence des anaerobies du genre clostridium dans les urocultures, Arch. Roum. Pathol. Exp. Microbial. 22: 405 (1969). 5. KUKLINCA,A. G., and GAVAN,T. L.: The culture of sterile urine for detection of anaerobic bacteria-not necessary for standard evaluation, Cleve. Clin. Q. 36: 133 (1969). 6. ALLING, B., BRANDBERG,A., SEEBERG, S., and SVANAerobic and anaerobic microbial flora in the BORG, A.: urinary tract of geriatric patients during long-term care, J. Infect. Dis. 127: 34 (1973). M. L., and LAURSEN,H.: Clos7. LYKKEGARD-NIELSEN, tridial infection in the urinary tract, Stand. J. Urol. Nephrol. 6: 120 (1972). Studies of urinary 8. LINDNER,A., and CUTLER, R. E.: pO2 in humans, Invest. Urol. 11: 21 (1973).
CYSTITIS EMPHYSEMATOSA*
JON S. WAYLAND,
M.D.
MARK D. KIVIAT,
M.D.
From the Department of Urology, Harbor-view Medical and University of Washington, Seattle, Washington
Center,
ABSTRACT - Two cases of cystitis emphysematosa with clostridial bacteremia are presented, and the potetitial importance of anaerobic organisms in producing this condition is emphasized.
Infection associated with interstitial gas production brings to mind anaerobic infections except in the urinary tract where the very existence of anaerobic infection remains in doubt. Cystitis emphysematosa is an uncommon affliction characterized by gas within the wall and the lumen of the bladder. The condition is seen most commonly in patients with hyperglycemia, the organism recovered from the urine usually being Escherichia coli or Enterobacter aerogenes. Less commonly, proteus, Staphylococcus aureus, streptococci, nocardia, or yeast are isolated from the urine. The following case reports provide evidence that anaerobes of the genus Clostridium may play a role in the causation of cystitis emphysematosa. Case Reports Case 1 An eighty-year-old man had nausea, vomiting, and mental confusion. He was a known diabetic. On physical examination, his vital signs were normal, chest was clear, and there was suprapubic tenderness. All laboratory data were normal except for blood sugar of 165 mg. per 100 ml., and urinalysis revealing glycosuria, ketonuria, and 10 to 15 white blood cells per high-power field. Aerobic urine culture was sterile. Blood culture drawn during a fever spike following catheterization for urinary retention recovered Clostridium welchii. An emphysematous ring was noted about a large bladder diverticulum on excretory urogram (Fig. 1). On postmortem examination, no hepatic or biliary abnormalities were disclosed which might have explained the clostridial sepsis.
*Supported
UHoLoC:I;
in part by Urology
/
XO\‘E.MBEH
1Y74
/
Special Fund.
VOLUME
IV, NUMBER
5
Case 2 A sixty-two-year-old woman was admitted with jaundice, hyperglycemia, and urinary retention. Her temperature was 99.4” F., the remainder of the vital signs being entirely normal. There was no hepatosplenomegaly. A roentgenogram revealed an emphysematous ring around the bladder (Fig. 2). Aerobic culture of the urine was sterile, while C. perfringens was isolated from the blood. The white blood cell count was 17,200, and urinalysis documented 4 to 20 white blood cells per high-power field. A thorough evaluation of the gastrointestinal tract, including liver scan, intravenous cholangiogram, upper gastrointestinal series, and barium enema failed to reveal any abnormality. The patient responded to 12 million units of penicillin daily for ten days; but after the antibiotic was discontinued, clostridia were again recovered from her blood. Intravenous cephalosporin finally proved effective. Subsequently insulin was required to control her diabetes. Comment These 2 cases illustrating cystitis emphysematosa with recovery of clostridia on blood culture and no organism from the aerobic urine culture constitute evidence that anaerobic organisms may have clinical importance. Burnes’ first implicated clostridia as a cause of cystitis emphysematosa in 1943; however, various authors have documented the recovery of anaerobes from urine of patients, the majority of which were asymptomatic. On reviewing the literature on anaerobic infections of the urinary tract, Finegold et al. ’ found 1 case of cystitis and 3 cases of pyelonephritis from which C. perfringens were isolated. Headington and Beyerlein3 isolated 195 anaerobes from 15,250 urine
so1
ring; (B) cystogram demonstrating diverticulum FIGURE 1. (A) Plain x-ray film ofpelvis showing- emphysematous .outlined by gas on plain film. - . specimens, clostridia representing 57 of the 195 isolates. Only 7 of the 195 patients were symptomatic. Similarly, Bittner et al. 4 found clostridia in only 1 of 400 urine cultures, and Kuklinca and Gavan5 found 1 patient in 200, a diabetic, positive for clostridia. Alling et ~1.~ on the other hand, recovered clostridia from 1 of 44 cultures in a group of incontinent geriatric patients. Perhaps the best documented case that clostridia may produce symptoms of cystitis is the report of Lykkegard-Nielsen and Laursen.’ They consistently isolated clostridia in multiple urine specimens until their patient became asymptomatic. The low but consistent incidence of anaerobic isolates from the urine raises the questions of how and where the organisms attain their ecologic niche. Clostridia are anaerobic or microaerophilic. The tolerance to oxygen varies with the species; for example, C. tetani will not form surface colonies if the air pressure exceeds 4.5 mm. Hg, while C. perfringens will tolerate up to 90 mm. Hg. In this regard, the presence of a re-
FIGURE 2. Plainfilm of abdomen showing huge bladder with gas in wall.
ducing sugar, 0.2 to 1 per cent glucose or a more efficient reductant such as cysteine, may well produce the reduced conditions necessary for the most fastidious of anaerobes. Glycosuria was a salient feature of both cases presented here. A second mechanism may also be operative. Little information is available regarding urinary oxygen tension, and published reports document wide variation in urinary ~02, a range of 4 to 70 mm. Hg.s In the case of retention and its associated distention of the bladder, the perfusion of the bladder may well be compromised, in which event the urothelium may further deplete the urinary pO2 and promote the growth of anaerobes. Seattle,
Washington 98195 (DR. KIVIAT)
References 1. BURNS,R. A.: Cystitis emphysematosa: a case report, J. Urol. 49: 808 (1943). 2. FINEGOLD,S. M., MILLER, L. G., MERRILL, S. L., and POSNICK,D. J.: Significance of anaerobic and capnophilic bacteria isolated from the urinary tract, in Kass, E. J.: Progress in Pyelonephritis, Philadelphia, F. A. Davis Co., 1965, p. 159. 3. HEADINGTON, J. T., and BEYERLEIN, B.: Anaerobic bacteria in routine urine culture, J. Clin. Pathol. 19: 573 (1966). 4. BITTNER, J., et al. : Incidence des anaerobies du genre clostridium dans les urocultures, Arch. Roum. Pathol. Exp. Microbial. 22: 405 (1969). 5. KUKLINCA,A. G., and GAVAN,T. L.: The culture of sterile urine for detection of anaerobic bacteria-not necessary for standard evaluation, Cleve. Clin. Q. 36: 133 (1969). 6. ALLING, B., BRANDBERG,A., SEEBERG, S., and SVANAerobic and anaerobic microbial flora in the BORG, A.: urinary tract of geriatric patients during long-term care, J. Infect. Dis. 127: 34 (1973). M. L., and LAURSEN,H.: Clos7. LYKKEGARD-NIELSEN, tridial infection in the urinary tract, Stand. J. Urol. Nephrol. 6: 120 (1972). Studies of urinary 8. LINDNER,A., and CUTLER, R. E.: pO2 in humans, Invest. Urol. 11: 21 (1973).