Eosinophilic Cystitis

Eosinophilic Cystitis

Vol. JI~. September Printed in THE JOURNAL OF UROLOG\ Copyright© 1974 by The Williams & Wilkins Co. EOSINOPHILIC CYSTITIS FRAY F. MARSHALL* AND A...

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Vol. JI~. September Printed in

THE JOURNAL OF UROLOG\

Copyright© 1974 by The Williams & Wilkins Co.

EOSINOPHILIC CYSTITIS FRAY F. MARSHALL*

AND

ANTHOi'IY W. MIDDLETON, ,JR.t

From the Department of Urology, Massachusetts General Hospital, Boston, Massachusetts

The first case of eosinophilic cystitis was reported Brown in 1960. 1 Subsequently, 12 cases have been cited in the literature. 2 -s We herein report 2 cases, review theories and outline management. CASE REPORT

Case 1. T. 081-42-04, a 40-year-old white man, was hospitalized because of a 4-day history of intermittent, gross, painless hematuria. He denied dysuria, fever or voiding. Except for several of medical history was negative. The patient's home was in Honduras but, with the exception of brief to Morocco, he had lived entirely in the Western Hemisphere. He smoked 1 ½ of cigarettes daily and denied any significant allergies or asthma. Physical examination was unremarkable with the exception of a small amount of blood at the urethral meatus. Urinalysis showed a 2 protein, 5 to 8 white blood cells (WBCs) and red cells too numerous to count. The urine culture was sterile. Hematocrit was 45.5 volumes per cent and the WBC was 8,600 per mm." Differential WBC was not performed preoperatively. Blood urea nitrogen (BUN), creatinine and electrolytes were within normal limits. An excretory urogram (IVP) showed normal upper tracts and a filling defect the right bladder wall. Cystoscopy was performed and a 1 cm. polypoid, erythematous lesion lateral to the right ureteral orifice was resected transurethrally. A bladder tumor was suspected microscopic sections demonstrated eosinophilic cystitis. This Accepted for publication March 22, 1974. * Requests for reprints: Department of Urology, Massachusetts General Hospital, Boston, Massachusetts 02114, t Current address: University of Utah Medical Center, Salt Lake City, Utah 84112. 1 Brown, E. W.: Eosinophilic granuloma of the bladder. J. Urol,, 83: 665, 1960. 2 Palubinskas, A. ,J.: Eosinophilic cystitis: case report of eosinophilic infiltration of the urinary bladder. Radiology, 75: 589, 1960. 3 Farber, S. and Vawter, G. F.: Clinical pathological conference. J. Pediat., 62: 941, 196:1. 4 Wenzl, J. E., Greene, L. F. and Harris, L. E.: Eosinophilic cystitis. J. Pediat., 64: 746, 1964. 5 Champion, R. H. and Ackles, R. C.: Eosinophilic cystitis. J. Urol., 96: 729, 1966. 'Perlmutter, A. D., Edlow, ,J. B. and Kevy, S. V.: Toxocara antibodies in eosinophilic cystitis. J. Pediat ., 73: 340, 1968. 7 Goldstein, M.: Eosinophilic cystitis ..J. Urol., 106: 854, 1971. 'Frensitli, F. ,J., Sacher, E. C. and Keegan, G. T.: Eosinophilic cystitis: observations on etiology. J. Urol., Hl7: 595, 1972.

eosinophilic infiltration was found in all primarily in the lamina propria (fig. 1). tively, the differential WBC showed 3 per cent eosinophils. Although followup is limited the patient's continued absence from the United States he was asymptomatic and had clear urine ;3 months postoperatively. Case 2. H. E., 040-94-52, a white man, was hospitalized in September 1972 ·with total, gross, painless hematuria. He had a

FIG.

1

of longstanding urinary obstructive symptoms and was hospitalized in December 1971 for zoster, at which time WBC and differential were normal. Evaluation during that hospitalization of splenomegaly and leukopenia prompted a bone marrow aspiration, which was normal. Eosinophilia was not present on the peripheral blood smear. Significant allergy was denied. On examination the prostate was large and benign tcpalpation. Hematocrit was 36 volumes per cent

336

MARSHALL AND MIDDLETON

urine culture was sterile. The WBC was 6,400 per mm. 3 and 1 eosinophil was present on the differential WBC. Urinary cytology was negative repeatedly. Rheumatoid factor was also negative. Stool for ova and parasites demonstrated an asymptomatic Giardia lamblia infestation which was not thought to be related to cystitis. Toxocara and schistosomiasis antibody studies were negative.

and the WBC was 5,600 per mm. 3 The differential eosinophil count was 11 per cent initially but decreased to 2 per cent postoperatively. BUN, creatinine and serum acid phosphatase values were normal. An IVP showed normal upper tracts and a trabeculated bladder. Cystoscopy revealed marked trabeculation of the bladder, hyperemia and edema of the left lateral wall. At the time of suprapubic prostatectomy a biopsy of the left lateral wall showed an infiltration of eosinophils primarily in the muscularis and mucosa (fig. 2). Followup at 15 months revealed the patient to be free of symptoms. Urinalysis showed a 1 plus protein and 3 WBCs per high power field. The

DISCUSSION

Goldstein and Frensilli suggested that an allergic reaction may be responsible for eosinophilic cystitis. 7 • 8 They noted the incrimination of a

FIG. 2

Sex-Age

Reference

Eosinophil Count ('c)

Symptoms

Findings at Cystoscopy and Other Observations

Brown 1

F-50

Hematuria

Palubinskas'

F
36

Farber and Vawter'

F-:J

Abdominal swelling, dysuria, frequency Dysuria, hematuria

Multiple plaques, \,-- ", cm. lesions, previously received 2,000R for rt. ovarian teratoma Thick bladder wall with normal trigone. history of

4-25

Multiple verrucose and polypoid folds suggested

Hematuria

Eosinophilia

Initial cystoscopy·-no specific description, followup

Wenzl and associates'

M-6 (cousin of preceding case) F-6

Champion and Ackles'

F-2

Perlmutter and

M-12 M-8

Dysuria, hematuria

Dysuria, frequency

11-22 3,

F-49

Hematuria, frequency

5

Uremia, hematuria Cystitis Cystitis

12-20 12

eosinophilic ileitis sarcoma

associates

6

!

was present

Abdominal pain, hematuria Dysuria

6

Multiple ulcerated areas

17

Bullous edema, clusters of red globules suggesting

I

Goldstein'

M-48 M-53 Frensilli and associates' F -19 Present study F-27 I M-40 I M-75

cystoscopy was negati\·e

Frequency, urgency

27

Hematuria Hematuria

3 2-11

sarcoma. previous rt. ovarian teratoma 1 cm, red polypoid lesion Mucosa ess.entially normal appearing, mass on dome suggesting tumor, Toxocara cati antibodies present Shaggy. ulcerated area of plaques 5-10 mm. suggested invasive tumor Thick-walled bladder, traheculation, cellules Diffuse inflammation Several areas of velvety, erythematous elevations Several large polypoid mucosa} lesions 1 cm. sessile, polypoid lesion suggested tumor Marked inflammation of bladder wall

EOS!NOP!-lILIC CYSTITIS

st1.lfonam.i.de therap:y. 9 These

suifonamide as sulfa.diazine and sulf<1nilsrLide. paras]tic bladder infiltration as the cy~.;Jitis hematuria, trate in the bladder wa!L As noted in the table all of the symptoms, have been noted in but in none coul.d evidence of schistosomiasis be found, One case in the liternture wouid appear to 6 based on an increase be related to Toxocara and anti-B wu'llc,w,a,""' titers, eo-

larva dogs cats but with humans, In the case 9 French, A. J,: histopathologic changes chemotherapy, Arner, J, Path., 22: 679, 1946,

must sites and infectiot1s.

involvement steroids,' StJMl\/1ARY

are are sun,,ma.rizecL

reviewed. The and/or hematuria noted and the marked gross to nant bladder tumor is observed. The young age the and should alert the Treatrne:nt agec.-t must remain is found.