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Emphysematous Cystitis Associated with Clostridium Perfringens Bacteremia
0022-534 7/79/1216-0819$02. 00/0
Vol. 121, June Printed in U.S.A.
THE JOURNAL OF UROLOGY
Copyright © 1979 by The Williams & Wilkins Co.
EMPHYSEMATOUS CYSTITIS ASSOCIATED WITH CLOSTRIDIUM PERFRINGENS BACTEREMIA NITAYA MALIWAN* From the Veterans Administration Hospital, Hines and the Department of Medicine, Abraham Lincoln School of Medicine, The University of Illinois C allege of Medicine, Chicago, Illinois.
ABSTRACT
Anaerobes are recognized rarely as the cause of urinary tract infection. A case is reported in which there were clinical signs of sepsis, positive blood culture for Clostridium perfringens and radiographic demonstration of emphysematous cystitis without any other recognized source of infection. majority of patients had chronic urinary tract infection owing to gas-producing organisms, namely Escherichia coli and Aerobacter aerogenes. Others less frequently found were Proteus mirabilis, Klebsiella pneumoniae, Staphylococcus aureus, Streptococci, Nocardia and Candida albicans. No comment was made regarding anaerobic organisms. Recent sporadic case reports showed similar findings. z, 3 The role of anaerobes in urinary tract infection is not well defined. Anaerobic culture of the urine has not been done routinely since the organism can normally be found in the urethral meatus and, thus, the significance of positive cultures from even catheterized specimens is uncertain. Headington and Beyerlein found 195 anaerobes from 15,250 consecutive urine specimens obtained either by catheterization or midstream collection.4 Only 62 were pure anaerobic cultures, 36 of which were Lactobacillus and 5 were Clostridium. Clinical records from 147 patients, representing 158 anaerobic isolates, including those from whom pure anaerobes were cultured, did not yield solid evidence for their roles in the urinary tract infection. With the use of suprapubic bladder aspiration and a strict anaerobic culture technique Segura and associates found a 1.3 per cent incidence of anaerobic bacteria from specimens with Gram stain-documented significant bacteriuria. 5 Bacteroides species were the most common organism and Clostridium was not recovered in this group. In all but 1 patient aerobes also were recovered and, also except for 1, all had significant underlying urologic disease. Of 114 patients with positive cultures for Clostridium, including 49 patients with positive blood cultures, the urinary tract was not recognized as a source of infection except in 1 case with a prostatic abscess without bacteremia. 6 COMMENT The presence of numerous bacteria on urinalysis in this patient, together with negative aerobic urine culture, strongly In an extensive review of the literature Bailey found 52 cases of cystitis emphysematosa, the condition in which gas suggested the possibility of anaerobes. However, it was unforvesicles are present in the wall of the bladder, and 46 cases of tunate that neither Gram stain nor suprapubic aspiration was primary pneumaturia, in which gas is located in the lumen of done. The pathogenesis of Clostridium sepsis in this case is the bladder. 1 He indicated the essential identity of these 2 not entirely clear. Several investigations did not reveal any conditions as being different stages of the same disease and underlying disease, including chronic pyelonephritis, stone, occasionally occurring concomitantly. Bailey also reported 19 obstructive uropathy, diabetes and vesicocolic or vesicovaginal additional cases of his own. The incidence of diabetes mellitus fistula. It is possible that Clostridium perfringens, originating was high (57 of 117 total cases). Other underlying or precipi- from the urethral meatus or rectum, gained access to the tating causes included cystoscopy, penetrating injury to the bladder by way of direct extension or local hematolymphanbladder, presence of a vesicocolic or vesicovaginal fistula, gial spread. Severe hypokalemia might have precipitated urinary stasis secondary to benign or malignant prostatic bladder stasis as an underlying condition in this case, similar hypertrophy, neurogenic bladder and vesical diverticula. The to those produced by diabetes mellitus and other neurogenic conditions. To my knowledge there have been only 2 previous cases reported of cystitis emphysematosa associated with Accepted for publication September 8, 1978. * Requests for reprints: Hines Veterans Administration ij:ospital, Clostridium perfringens bacteremia. 7 Both patients were diaBox 1017, Hines, Illinois 60141. betic and had sterile aerobic urine cultures and 1 died.
A 38-year-old woman was hospitalized with a chief complaint of bladder retention. She had been drinking alcohol excessively for several years and experienced nausea, vomiting and a slight weight loss during the last 8 months. Lower abdominal pain, dysuria and gross hematuria occurred a few days previously. There was no history of diabetes in the family. Physical examination revealed a poorly responsive, thin, black woman in no acute distress. Temperature was 38.5C. She had a mild degree of tenderness over the entire abdomen but it was more pronounced over the suprapubic region where a distended bladder was palpable. Foley catheterization yielded 200 cc cloudy brownish fluid. The white blood count was 12,100 with 86 per cent neutrophils. Urinalysis showed numerous red and white blood cells, and bacteria. Routine urine culture yielded no growth. Blood chemistry studies showed mild elevation of the liver enzymes and serum potassium was 2.4 mEq./1. The patient was given fluid and electrolyte replacement. Investigations for fever and abdominal pain included a negative upper and lower gastrointestinal and gallbladder series. An excretory urogram (IVP) for persistent hematuria revealed normal kidneys and ureters but there was gas collection in the wall of the dome of the bladder (parts A and B of figure). The patient remained febrile and blood culture yielded Clostridium perfringens. Aqueous penicillin G was given intravenously at 2.5 million units every 6 hours with a prompt defervescent response. A followup IVP showed a normal bladder (parts C andD of figure).
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MALIWAN
A, anteroposterior and B, oblique views of initial IVP show definite mucosal separation by gas over dome of bladder. C, anteroposterior and D, oblique views of followup IVP reveal restoration of mucosal pattern. REFERENCES
1. Bailey, H.: Cystitis emphysematosa: 19 cases with intraluminal and interstitial collections of gas. Amer. J. Roentgen., 86: 850,
1961. 2. Holesh, S.: Gas in the bladder. Cystitis emphysematosa. Clin. Rad., 20: 234, 1969. 3. Hawtrey, C. E., Williams, J. J. and Schmidt, J. D.: Cystitis emphysematosa. Urology, 3: 612, 1974. 4. Headington, J. T. and Beyerlein, B.: Anaerobic bacteria in
routine urine culture. J. Clin. Path., 19: 573, 1966. 5. Segura, J. W., Kelalis, P. P., Martin, W. J. and Smith, L. H.: Anaerobic bacteria in the urinary tract. Mayo Clin. Proc., 47: 30, 1972. 6. Gorbach, S. L. and Thadepalli, H.: Isolation of Clostridium in human infections: evaluation of 114 cases. J. Infect. Dis. (suppl.), 131: S81, 1975. 7. Wayland, J. S. and Kiviat, M. D.: Clostridial cystitis emphysematosa. Urology, 4: 601, 1974.
Vol. 121, June Printed in U.S.A.
THE JOURNAL OF UROLOGY
Copyright © 1979 by The Williams & Wilkins Co.
EMPHYSEMATOUS CYSTITIS ASSOCIATED WITH CLOSTRIDIUM PERFRINGENS BACTEREMIA NITAYA MALIWAN* From the Veterans Administration Hospital, Hines and the Department of Medicine, Abraham Lincoln School of Medicine, The University of Illinois C allege of Medicine, Chicago, Illinois.
ABSTRACT
Anaerobes are recognized rarely as the cause of urinary tract infection. A case is reported in which there were clinical signs of sepsis, positive blood culture for Clostridium perfringens and radiographic demonstration of emphysematous cystitis without any other recognized source of infection. majority of patients had chronic urinary tract infection owing to gas-producing organisms, namely Escherichia coli and Aerobacter aerogenes. Others less frequently found were Proteus mirabilis, Klebsiella pneumoniae, Staphylococcus aureus, Streptococci, Nocardia and Candida albicans. No comment was made regarding anaerobic organisms. Recent sporadic case reports showed similar findings. z, 3 The role of anaerobes in urinary tract infection is not well defined. Anaerobic culture of the urine has not been done routinely since the organism can normally be found in the urethral meatus and, thus, the significance of positive cultures from even catheterized specimens is uncertain. Headington and Beyerlein found 195 anaerobes from 15,250 consecutive urine specimens obtained either by catheterization or midstream collection.4 Only 62 were pure anaerobic cultures, 36 of which were Lactobacillus and 5 were Clostridium. Clinical records from 147 patients, representing 158 anaerobic isolates, including those from whom pure anaerobes were cultured, did not yield solid evidence for their roles in the urinary tract infection. With the use of suprapubic bladder aspiration and a strict anaerobic culture technique Segura and associates found a 1.3 per cent incidence of anaerobic bacteria from specimens with Gram stain-documented significant bacteriuria. 5 Bacteroides species were the most common organism and Clostridium was not recovered in this group. In all but 1 patient aerobes also were recovered and, also except for 1, all had significant underlying urologic disease. Of 114 patients with positive cultures for Clostridium, including 49 patients with positive blood cultures, the urinary tract was not recognized as a source of infection except in 1 case with a prostatic abscess without bacteremia. 6 COMMENT The presence of numerous bacteria on urinalysis in this patient, together with negative aerobic urine culture, strongly In an extensive review of the literature Bailey found 52 cases of cystitis emphysematosa, the condition in which gas suggested the possibility of anaerobes. However, it was unforvesicles are present in the wall of the bladder, and 46 cases of tunate that neither Gram stain nor suprapubic aspiration was primary pneumaturia, in which gas is located in the lumen of done. The pathogenesis of Clostridium sepsis in this case is the bladder. 1 He indicated the essential identity of these 2 not entirely clear. Several investigations did not reveal any conditions as being different stages of the same disease and underlying disease, including chronic pyelonephritis, stone, occasionally occurring concomitantly. Bailey also reported 19 obstructive uropathy, diabetes and vesicocolic or vesicovaginal additional cases of his own. The incidence of diabetes mellitus fistula. It is possible that Clostridium perfringens, originating was high (57 of 117 total cases). Other underlying or precipi- from the urethral meatus or rectum, gained access to the tating causes included cystoscopy, penetrating injury to the bladder by way of direct extension or local hematolymphanbladder, presence of a vesicocolic or vesicovaginal fistula, gial spread. Severe hypokalemia might have precipitated urinary stasis secondary to benign or malignant prostatic bladder stasis as an underlying condition in this case, similar hypertrophy, neurogenic bladder and vesical diverticula. The to those produced by diabetes mellitus and other neurogenic conditions. To my knowledge there have been only 2 previous cases reported of cystitis emphysematosa associated with Accepted for publication September 8, 1978. * Requests for reprints: Hines Veterans Administration ij:ospital, Clostridium perfringens bacteremia. 7 Both patients were diaBox 1017, Hines, Illinois 60141. betic and had sterile aerobic urine cultures and 1 died.
A 38-year-old woman was hospitalized with a chief complaint of bladder retention. She had been drinking alcohol excessively for several years and experienced nausea, vomiting and a slight weight loss during the last 8 months. Lower abdominal pain, dysuria and gross hematuria occurred a few days previously. There was no history of diabetes in the family. Physical examination revealed a poorly responsive, thin, black woman in no acute distress. Temperature was 38.5C. She had a mild degree of tenderness over the entire abdomen but it was more pronounced over the suprapubic region where a distended bladder was palpable. Foley catheterization yielded 200 cc cloudy brownish fluid. The white blood count was 12,100 with 86 per cent neutrophils. Urinalysis showed numerous red and white blood cells, and bacteria. Routine urine culture yielded no growth. Blood chemistry studies showed mild elevation of the liver enzymes and serum potassium was 2.4 mEq./1. The patient was given fluid and electrolyte replacement. Investigations for fever and abdominal pain included a negative upper and lower gastrointestinal and gallbladder series. An excretory urogram (IVP) for persistent hematuria revealed normal kidneys and ureters but there was gas collection in the wall of the dome of the bladder (parts A and B of figure). The patient remained febrile and blood culture yielded Clostridium perfringens. Aqueous penicillin G was given intravenously at 2.5 million units every 6 hours with a prompt defervescent response. A followup IVP showed a normal bladder (parts C andD of figure).
!
819
820
MALIWAN
A, anteroposterior and B, oblique views of initial IVP show definite mucosal separation by gas over dome of bladder. C, anteroposterior and D, oblique views of followup IVP reveal restoration of mucosal pattern. REFERENCES
1. Bailey, H.: Cystitis emphysematosa: 19 cases with intraluminal and interstitial collections of gas. Amer. J. Roentgen., 86: 850,
1961. 2. Holesh, S.: Gas in the bladder. Cystitis emphysematosa. Clin. Rad., 20: 234, 1969. 3. Hawtrey, C. E., Williams, J. J. and Schmidt, J. D.: Cystitis emphysematosa. Urology, 3: 612, 1974. 4. Headington, J. T. and Beyerlein, B.: Anaerobic bacteria in
routine urine culture. J. Clin. Path., 19: 573, 1966. 5. Segura, J. W., Kelalis, P. P., Martin, W. J. and Smith, L. H.: Anaerobic bacteria in the urinary tract. Mayo Clin. Proc., 47: 30, 1972. 6. Gorbach, S. L. and Thadepalli, H.: Isolation of Clostridium in human infections: evaluation of 114 cases. J. Infect. Dis. (suppl.), 131: S81, 1975. 7. Wayland, J. S. and Kiviat, M. D.: Clostridial cystitis emphysematosa. Urology, 4: 601, 1974.