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Emphysematous Cystitis: A Rare Cause of Gross Hematuria
The Journal of Emergency Medicine, Vol. 40, No. 5, pp. 506 –508, 2011 Copyright © 2011 Elsevier Inc. Printed in the USA. All rights reserved 0736-4679/$–see front matter
doi:10.1016/j.jemermed.2007.11.068
Clinical Communications: Adults
EMPHYSEMATOUS CYSTITIS: A RARE CAUSE OF GROSS HEMATURIA Chirn-Bin Chang,
MD*
and Chia-Chu Chang,
MD*†
*Nephrology Division, Department of Internal Medicine, Changhua Christian Hospital, Changhua, Taiwan and †College of Health Sciences, Institute of Medical Research, Chang Jung Christian University, Tainan, Taiwan Reprint Address: Chia-Chu Chang, MD, Department of Internal Medicine, Changhua Christian Hospital, No 135 Nan-Siau Street, Changhua 500, Taiwan
e Abstract—Emphysematous cystitis is a relatively rare infectious condition of the urinary bladder. The mortality rate is high if the diagnosis is delayed or if the treatment is inadequate. We present an uncommon case of emphysematous cystitis and highlight the risk factors for this disease. An 81-year-old man with a past medical history of type 2 diabetes and a central pontine infarction presented to the Emergency Department due to gross hematuria. Computed tomography (CT) and plain radiography revealed localized gas within the bladder that was compatible with the diagnosis of emphysematous cystitis. A Foley catheter was inserted. Urine culture grew Klebsiella pneumoniae; 2 g cefotaxime daily was initiated. Subsequent plain radiography and CT scan showed regression of intraluminal gas. We recommend CT for the definitive diagnosis of emphysematous cystitis. Adequate antibiotic therapy, strict blood glucose control, adequate drainage of urine, and early goal-directed therapy for suspected sepsis are suggested to prevent the complications of emphysematous cystitis. © 2011 Elsevier Inc.
presented to increase awareness of this entity and the variety of presentations. CASE REPORT An 81-year-old man with a past medical history of type 2 diabetes and a central pontine infarction presented to the Emergency Department (ED) due to blood-tinged urine in his diaper and air bubbles seen during urinary catheterization. Due to the patient’s neuropathic bladder with decreased detrusor contractility, urinary catheterization had been performed three times daily for more than 1 year. Vital signs on admission to the ED were: blood pressure 120/70 mm Hg, pulse 90 beats/min, respiration 15 breaths/min, and temperature 36°C. Physical examination revealed a distended abdomen with mild suprapubic tenderness on palpation. There was no rebound pain or muscle guarding. Physical examination of the head, neck, chest, heart, genital organs, and rectum were unremarkable. Laboratory studies showed the following: non-fasting plasma glucose 270 mg/dL, creatinine 3.4 mg/dL, leukocytes 9200/L, and segmented neutrophils 70%. Urinalysis revealed glucose 0.1 g/dL, occult blood 4⫹, pH 6.5, numerous leukocytes and erythrocytes, and bacteriuria. Initially, cefazolin 1 g twice daily was given as empiric treatment. Plasma glucose concentration was strictly controlled with insulin. Plain radiography revealed radiolucent gas around the bladder (Figure 1). A Foley catheter was inserted for adequate drainage of
e Keywords— emphysematous cystitis; hematuria
INTRODUCTION Emphysematous cystitis is a relatively rare infectious condition of the urinary bladder. This complicated urinary tract infection can ascend to the kidney or adrenal gland with a high mortality rate if the diagnosis is delayed or if the treatment is inadequate (1). This case is
RECEIVED: 16 February 2007; FINAL ACCEPTED: 13 November 2007
SUBMISSION RECEIVED:
13 June 2007; 506
Emphysematous Cystitis
507
Figure 3. Subsequent computed tomography scan revealing little gas in the bladder. Figure 1. Plain radiograph showing radiolucent gas around the bladder.
urine. Computed tomography (CT) revealed a definite location of gas within the bladder compatible with the diagnosis of emphysematous cystitis (Figure 2). After a urine culture revealed Klebsiella pneumoniae, antibiotic therapy was changed to cefotaxime 2 g daily. Ten days later, the patient’s condition improved with no other signs of systemic inflammatory response. A subsequent plain radiograph and CT scan showed regression of intraluminal gas accumulation (Figure 3). DISCUSSION Emphysematous cystitis is a rare infectious condition of the urinary bladder. Previous publications have described
Figure 2. Computed tomography scan through the bladder revealing gas in the intramural space and in the lumen.
the symptoms as urinary hesitancy, poor urine stream, hematuria, dysuria, abdominal pain, and rarely, pneumaturia (2). However, our patient did initially present with pneumaturia, which was a clue to his condition. Causative organisms of emphysematous cystitis include Escherichia coli, Enterobacter aerogenes, Staphylococcus species, Streptococcus species, Klebsiella species, Proteus species, Nocardia species, and Candida albicans; otherwise, the anaerobic organism Clostridium perfringens has also been reported (1,3,4). At least 50% of these patients had diabetes mellitus and bladder outlet obstruction. Other predisposing factors include being immunocompromised or female (incidence rate 2:1 between women and men) and having chronic urinary tract infections, lupus cystitis, and neuropathic bladders (4,5). The hypotheses to explain these unusual infectious conditions comprise four factors: 1) glucose or albumin in urine is the source for fermentation to hydrogen and carbon dioxide, as suggested in previous publications; 2) obstruction of the bladder outlet or neuropathic bladder results in urine retention and rapid bacterial replication; 3) relative hypoperfusion due to diabetic microvasculopathy reduces the rate of gas dispersion; 4) necrotizing tissue is a weak barrier and gas dissects the intraluminal space (1,2,6 –9). Several imaging modalities have been used to diagnose emphysematous cystitis. Trabeculous changes in the bladder wall and ultrasound images of gas with acoustic shadows around the bladder wall necessitate the following imaging studies for definitive diagnosis: plain radiography can reveal air and the soft-tissue doughnut sign in the pelvis; also evident can be a radiolucent line of gas around the bladder wall, “cobblestone” in appearance, and gas evident within the lumen (4,10 –12). This finding during plain radiography should be differentiated from findings that lead to a diagnosis of rectal gas,
508
C.-B. Chang and C.-C. Chang
emphysematous vaginitis, pneumatosis cystoides intestinalis, and gas gangrene of the uterus (7,11). In our patient, the gas was obvious and may have been related to a period of accumulation of 2 weeks. CT is used as a more sensitive tool and reveals the anatomic status around the urinary bladder and extent of gas collection. It can be adapted to exclude other complicated conditions such as colovesical or vaginovesical fistula, or an ascending infection of the upper urinary tract such as emphysematous pyelonephritis or emphysematous pyelitis (11,13). When accumulated gas in the bladder is due to a colovesical fistula, the most common cause is diverticulitis of the colon, colon carcinoma or, less commonly, Crohn’s disease (14). CT with retrograde cystography, compared with cystoscopy or barium enema, has been reported to be a favorable method to identify a vesicocolic fistula (13). We suggest that CT is indicated for patients in whom gas accumulation within the lumen is revealed by plain radiography. Complicated conditions such as emphysematous pyelonephritis may need surgical intervention despite medical treatment. However, further study is necessary to define the incidence of these complications. Routine ultrasonography or plain radiographs are indicated for the febrile patient who is at risk for emphysematous cystitis, especially patients with diabetes mellitus, urinary outlet obstruction, or neuropathic bladder. CONCLUSION CT is recommended for the definitive diagnosis of emphysematous cystitis. After diagnosis of emphysematous cystitis, admission for adequate parenteral antibiotic therapy, strict blood glucose control, adequate drainage of urine, and early goal-directed therapy for septic pa-
tients are suggested to prevent further complications such as septic shock or emphysematous pyelonephritis and emphysematous pyelitis (3,6,9,15).
REFERENCES 1. Ankel F, Wolfson AB, Stapczynski JS. Emphysematous cystitis: a complication of urinary tract infection occurring predominantly in diabetic women. Ann Emerg Med 1990;19:404 – 6. 2. Jack CI, Robinson R, Lye M. Emphysematous cystitis in an elderly patient. Br J Clin Pract 1995;49:334 –5. 3. Bartkowski DP, Lanesky JR. Emphysematous prostatitis and cystitis secondary to Candida albicans. J Urol 1988;139:1063–5. 4. Kauzlaric D, Barmeir E. Sonography of emphysematous cystitis. J Ultrasound Med 1985;4:319 –20. 5. Patel NP, Lavengood RW, Fernandes M, Ward JN, Walzak MP. Gas-forming infections in genitourinary tract. Urology 1992;39: 341–5. 6. Granel B, Serratrice J, Juhan V. Lupus cystitis: a possible additive risk factor for emphysematous cystitis in diabetes mellitus: discussion about one case. Lupus 2000;9:72–3. 7. Huang JJ, Chen KW, Ruaan MK. Mixed acid fermentation of glucose as a mechanism of emphysematous urinary tract infection. J Urol 1991;146:148 –51. 8. Patterson JE, Andriole VT. Bacterial urinary tract infections in diabetes. Infect Dis Clin North Am 1997;11:735–50. 9. Schainuck LI, Fouty R, Cutler RE. Emphysematous pyelonephritis. A new case and review of previous observations. Am J Med 1968;44:134 –9. 10. Yang WH, Shen NC. Gas-forming infection of the urinary tract: an investigation of fermentation as a mechanism. J Urol 1990;43: 960 – 4. 11. Choong KK. Sonographic detection of emphysematous cystitis. J Ultrasound Med 2003;22:847–9. 12. Joseph RC, Amendola MA, Artze ME. Genitourinary tract gas: imaging evaluation. Radiographics 1996;16:295–308. 13. Asada S, Kawasaki T. Images in clinical medicine. Emphysematous cystitis. N Engl J Med 2003;349:258. 14. Labs JD, Sarr MG, Fishman EK, Siegelman SS, Cameron JL. Complications of acute diverticulitis of the colon: improved early diagnosis with computerized tomography. Am J Surg 1988;155: 331– 6. 15. Nemati E, Basra R, Fernandes J, Levy JB. Emphysematous cystitis. Nephrol Dial Transplant 2005;20:652–3.
doi:10.1016/j.jemermed.2007.11.068
Clinical Communications: Adults
EMPHYSEMATOUS CYSTITIS: A RARE CAUSE OF GROSS HEMATURIA Chirn-Bin Chang,
MD*
and Chia-Chu Chang,
MD*†
*Nephrology Division, Department of Internal Medicine, Changhua Christian Hospital, Changhua, Taiwan and †College of Health Sciences, Institute of Medical Research, Chang Jung Christian University, Tainan, Taiwan Reprint Address: Chia-Chu Chang, MD, Department of Internal Medicine, Changhua Christian Hospital, No 135 Nan-Siau Street, Changhua 500, Taiwan
e Abstract—Emphysematous cystitis is a relatively rare infectious condition of the urinary bladder. The mortality rate is high if the diagnosis is delayed or if the treatment is inadequate. We present an uncommon case of emphysematous cystitis and highlight the risk factors for this disease. An 81-year-old man with a past medical history of type 2 diabetes and a central pontine infarction presented to the Emergency Department due to gross hematuria. Computed tomography (CT) and plain radiography revealed localized gas within the bladder that was compatible with the diagnosis of emphysematous cystitis. A Foley catheter was inserted. Urine culture grew Klebsiella pneumoniae; 2 g cefotaxime daily was initiated. Subsequent plain radiography and CT scan showed regression of intraluminal gas. We recommend CT for the definitive diagnosis of emphysematous cystitis. Adequate antibiotic therapy, strict blood glucose control, adequate drainage of urine, and early goal-directed therapy for suspected sepsis are suggested to prevent the complications of emphysematous cystitis. © 2011 Elsevier Inc.
presented to increase awareness of this entity and the variety of presentations. CASE REPORT An 81-year-old man with a past medical history of type 2 diabetes and a central pontine infarction presented to the Emergency Department (ED) due to blood-tinged urine in his diaper and air bubbles seen during urinary catheterization. Due to the patient’s neuropathic bladder with decreased detrusor contractility, urinary catheterization had been performed three times daily for more than 1 year. Vital signs on admission to the ED were: blood pressure 120/70 mm Hg, pulse 90 beats/min, respiration 15 breaths/min, and temperature 36°C. Physical examination revealed a distended abdomen with mild suprapubic tenderness on palpation. There was no rebound pain or muscle guarding. Physical examination of the head, neck, chest, heart, genital organs, and rectum were unremarkable. Laboratory studies showed the following: non-fasting plasma glucose 270 mg/dL, creatinine 3.4 mg/dL, leukocytes 9200/L, and segmented neutrophils 70%. Urinalysis revealed glucose 0.1 g/dL, occult blood 4⫹, pH 6.5, numerous leukocytes and erythrocytes, and bacteriuria. Initially, cefazolin 1 g twice daily was given as empiric treatment. Plasma glucose concentration was strictly controlled with insulin. Plain radiography revealed radiolucent gas around the bladder (Figure 1). A Foley catheter was inserted for adequate drainage of
e Keywords— emphysematous cystitis; hematuria
INTRODUCTION Emphysematous cystitis is a relatively rare infectious condition of the urinary bladder. This complicated urinary tract infection can ascend to the kidney or adrenal gland with a high mortality rate if the diagnosis is delayed or if the treatment is inadequate (1). This case is
RECEIVED: 16 February 2007; FINAL ACCEPTED: 13 November 2007
SUBMISSION RECEIVED:
13 June 2007; 506
Emphysematous Cystitis
507
Figure 3. Subsequent computed tomography scan revealing little gas in the bladder. Figure 1. Plain radiograph showing radiolucent gas around the bladder.
urine. Computed tomography (CT) revealed a definite location of gas within the bladder compatible with the diagnosis of emphysematous cystitis (Figure 2). After a urine culture revealed Klebsiella pneumoniae, antibiotic therapy was changed to cefotaxime 2 g daily. Ten days later, the patient’s condition improved with no other signs of systemic inflammatory response. A subsequent plain radiograph and CT scan showed regression of intraluminal gas accumulation (Figure 3). DISCUSSION Emphysematous cystitis is a rare infectious condition of the urinary bladder. Previous publications have described
Figure 2. Computed tomography scan through the bladder revealing gas in the intramural space and in the lumen.
the symptoms as urinary hesitancy, poor urine stream, hematuria, dysuria, abdominal pain, and rarely, pneumaturia (2). However, our patient did initially present with pneumaturia, which was a clue to his condition. Causative organisms of emphysematous cystitis include Escherichia coli, Enterobacter aerogenes, Staphylococcus species, Streptococcus species, Klebsiella species, Proteus species, Nocardia species, and Candida albicans; otherwise, the anaerobic organism Clostridium perfringens has also been reported (1,3,4). At least 50% of these patients had diabetes mellitus and bladder outlet obstruction. Other predisposing factors include being immunocompromised or female (incidence rate 2:1 between women and men) and having chronic urinary tract infections, lupus cystitis, and neuropathic bladders (4,5). The hypotheses to explain these unusual infectious conditions comprise four factors: 1) glucose or albumin in urine is the source for fermentation to hydrogen and carbon dioxide, as suggested in previous publications; 2) obstruction of the bladder outlet or neuropathic bladder results in urine retention and rapid bacterial replication; 3) relative hypoperfusion due to diabetic microvasculopathy reduces the rate of gas dispersion; 4) necrotizing tissue is a weak barrier and gas dissects the intraluminal space (1,2,6 –9). Several imaging modalities have been used to diagnose emphysematous cystitis. Trabeculous changes in the bladder wall and ultrasound images of gas with acoustic shadows around the bladder wall necessitate the following imaging studies for definitive diagnosis: plain radiography can reveal air and the soft-tissue doughnut sign in the pelvis; also evident can be a radiolucent line of gas around the bladder wall, “cobblestone” in appearance, and gas evident within the lumen (4,10 –12). This finding during plain radiography should be differentiated from findings that lead to a diagnosis of rectal gas,
508
C.-B. Chang and C.-C. Chang
emphysematous vaginitis, pneumatosis cystoides intestinalis, and gas gangrene of the uterus (7,11). In our patient, the gas was obvious and may have been related to a period of accumulation of 2 weeks. CT is used as a more sensitive tool and reveals the anatomic status around the urinary bladder and extent of gas collection. It can be adapted to exclude other complicated conditions such as colovesical or vaginovesical fistula, or an ascending infection of the upper urinary tract such as emphysematous pyelonephritis or emphysematous pyelitis (11,13). When accumulated gas in the bladder is due to a colovesical fistula, the most common cause is diverticulitis of the colon, colon carcinoma or, less commonly, Crohn’s disease (14). CT with retrograde cystography, compared with cystoscopy or barium enema, has been reported to be a favorable method to identify a vesicocolic fistula (13). We suggest that CT is indicated for patients in whom gas accumulation within the lumen is revealed by plain radiography. Complicated conditions such as emphysematous pyelonephritis may need surgical intervention despite medical treatment. However, further study is necessary to define the incidence of these complications. Routine ultrasonography or plain radiographs are indicated for the febrile patient who is at risk for emphysematous cystitis, especially patients with diabetes mellitus, urinary outlet obstruction, or neuropathic bladder. CONCLUSION CT is recommended for the definitive diagnosis of emphysematous cystitis. After diagnosis of emphysematous cystitis, admission for adequate parenteral antibiotic therapy, strict blood glucose control, adequate drainage of urine, and early goal-directed therapy for septic pa-
tients are suggested to prevent further complications such as septic shock or emphysematous pyelonephritis and emphysematous pyelitis (3,6,9,15).
REFERENCES 1. Ankel F, Wolfson AB, Stapczynski JS. Emphysematous cystitis: a complication of urinary tract infection occurring predominantly in diabetic women. Ann Emerg Med 1990;19:404 – 6. 2. Jack CI, Robinson R, Lye M. Emphysematous cystitis in an elderly patient. Br J Clin Pract 1995;49:334 –5. 3. Bartkowski DP, Lanesky JR. Emphysematous prostatitis and cystitis secondary to Candida albicans. J Urol 1988;139:1063–5. 4. Kauzlaric D, Barmeir E. Sonography of emphysematous cystitis. J Ultrasound Med 1985;4:319 –20. 5. Patel NP, Lavengood RW, Fernandes M, Ward JN, Walzak MP. Gas-forming infections in genitourinary tract. Urology 1992;39: 341–5. 6. Granel B, Serratrice J, Juhan V. Lupus cystitis: a possible additive risk factor for emphysematous cystitis in diabetes mellitus: discussion about one case. Lupus 2000;9:72–3. 7. Huang JJ, Chen KW, Ruaan MK. Mixed acid fermentation of glucose as a mechanism of emphysematous urinary tract infection. J Urol 1991;146:148 –51. 8. Patterson JE, Andriole VT. Bacterial urinary tract infections in diabetes. Infect Dis Clin North Am 1997;11:735–50. 9. Schainuck LI, Fouty R, Cutler RE. Emphysematous pyelonephritis. A new case and review of previous observations. Am J Med 1968;44:134 –9. 10. Yang WH, Shen NC. Gas-forming infection of the urinary tract: an investigation of fermentation as a mechanism. J Urol 1990;43: 960 – 4. 11. Choong KK. Sonographic detection of emphysematous cystitis. J Ultrasound Med 2003;22:847–9. 12. Joseph RC, Amendola MA, Artze ME. Genitourinary tract gas: imaging evaluation. Radiographics 1996;16:295–308. 13. Asada S, Kawasaki T. Images in clinical medicine. Emphysematous cystitis. N Engl J Med 2003;349:258. 14. Labs JD, Sarr MG, Fishman EK, Siegelman SS, Cameron JL. Complications of acute diverticulitis of the colon: improved early diagnosis with computerized tomography. Am J Surg 1988;155: 331– 6. 15. Nemati E, Basra R, Fernandes J, Levy JB. Emphysematous cystitis. Nephrol Dial Transplant 2005;20:652–3.