Pyocystis: Two case reports of patients in renal failure1

The Journal of Emergency Medicine, Vol. 19, No. 2, pp. 131–133, 2000 Copyright © 2000 Elsevier Science Inc. Printed in the USA. All rights reserved 0736-4679/00 $–see front matter

PII S0736-4679(00)00198-0

Clinical Communications

PYOCYSTIS: TWO CASE REPORTS OF PATIENTS IN RENAL FAILURE Erica E. Remer,

MD, FACEP*†

and William Franklin Peacock, IV,

MD, FACEP*†

*The Cleveland Clinic Foundation, Cleveland, Ohio, and †The Ohio State University College of Medicine, Columbus, Ohio Reprint Address: Erica E. Remer, MD, FACEP, The Cleveland Clinic Foundation, M/C E-19, 9500 Euclid Avenue, Cleveland, OH 44195

e Abstract—Two cases of pyocystis in patients in endstage renal disease are reported. Pyocystis is a recognized complication of urinary diversion procedures, but also occurs in anuric or oliguric hemodialysis patients. The treatment differs from ordinary cystitis, requiring catheterization, bladder irrigation, and intravesical antibiotic instillation. When undiagnosed, pyocystis may progress to sepsis and death. © 2000 Elsevier Science Inc.

CASE 1 A 60-year-old woman with hypertension, diabetes mellitus, and end-stage renal disease managed by hemodialysis for the month preceding, presented to the emergency department (ED) complaining of abdominal pain similar to prior UTIs. She was chronically oliguric and had not noted any dysuria, hematuria, fever, or chills. On presentation, the temperature was 37.6°C, pulse 104 beats/ min, respirations 24 breaths/min, and blood pressure (BP) 153/77 mm Hg. On abdominal examination, there was a peritoneal dialysis catheter found. There was suprapubic tenderness without rebound or guarding. Her voided urine was turbid, with ⬎300 mg/dL protein, 3⫹ leukocyte esterase, ⬎25 white blood cells (WBC)/high power field (HPF), and 11–25 red blood cells/HPF. The urine culture yielded ⬎100,000 colony-forming units/mL Streptococcus viridans. The patient was diagnosed with cystitis. She was given a dose of intravenous gentamicin and discharged on trimethoprim/sulfamethoxazole (TMP/SMZ). Five days later, the patient returned to the ED with continuing suprapubic pain; urgency; and odoriferous, white, vaginal discharge. The temperature was 37.6°C, heart rate 104 beats/min, respirations 24 breaths/min, and BP 153/77 mm Hg. Palpation of the uterus caused discomfort, and gynecology was consulted. A pelvic ultrasound was ordered, but was unable to be performed because of excessive pain during instillation of saline into the bladder per Foley catheter. The ultrasound tech-

e Keywords— hemodialysis; pyocystis; renal disease; urinary diversion; urinary tract infection

INTRODUCTION Patients with nonfunctioning bladders, such as in anuric renal failure or surgically bypassed bladders, are prone to a severe form of urinary tract infection (UTI) called pyocystis. Also known as vesical empyema, pyocystis is the accumulation of pus in the bladder (1). Irrigation of the bladder for chronic cystitis was performed as early as 1896; however, pyocystis was not well recognized until the 1960s after urinary diversion procedures gained popularity and complications were noted (2,3). Catheterization of the bladder is crucial to obtain material for culture. Oral antibiotics may not be adequate for treatment, necessitating intravesical and parenteral antibiotics to eradicate the infection. The following cases describe typical presentations.

Clinical Communications (Adults) is coordinated by Ron M. Walls, MD, of Brigham and Women’s Hospital and Harvard University Medical Center, Boston, Massachusetts

RECEIVED: June 14, 1999; FINAL ACCEPTED: January 21, 2000

SUBMISSION RECEIVED:

October 25, 1999; 131

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E. E. Remer and W. F. Peacock

nician noted purulent discharge in the Foley catheter. On this visit, a complete blood count was drawn and demonstrated a white blood count of 10,200/mm3. A nephrologist was consulted and felt it unlikely that the etiology of the pain was from the urinary tract. Because of concern that the cystitis had not been completely eradicated, the patient was discharged on cephalexin. Because the patient still had an indwelling peritoneal dialysis catheter that was no longer being used, she was also instructed to follow up in the peritoneal dialysis clinic the next day for evaluation. A urine culture from the second ED visit did not grow any organisms, but the peritoneal fluid obtained the following day grew small amounts of Enterococcus and Enterobacter. She was hospitalized for 4 days to treat the peritonitis and was discharged on oral ampicillin, ciprofloxacin, and postdialysis gentamicin. Culture performed on removal of her continuous ambulatory peritoneal dialysis catheter showed no growth. Three days later, she returned to the ED with identical abdominal pain, fatigue, and anorexia. At that time, the temperature was 37.7°C, heart rate 114 beats/min, and BP 154/74 mmHg. The abdomen was soft, but tender in the suprapubic region, without rebound or guarding. The white blood count was 9,700/mm3. When purulent material was obtained on urinary catheterization, an indwelling catheter was placed. A urologic consultant then removed 300 mL of foul-smelling green pus, performed irrigation, and instilled intravesical gentamicin. By the next day, the patient was feeling greatly improved, no longer anorexic, and was nontender on physical examination. The culture of the gross pus did not grow any organisms.

CASE 2 A 68-year-old male with oliguric hemodialysis-dependent renal failure had coffee ground emesis at the nursing home. The medications included Nephrocaps, calcium acetate, and TMP/SMZ. His temperature was 39.1°C, pulse was 139 beats/min, respirations were 32 breaths/ min, and BP was 104/49 mmHg. On physical examination, he was contractured and minimally responsive even to noxious stimuli. He appeared dehydrated. The lung examination demonstrated bilateral rales and occasional wheezing. The abdomen was soft without masses or guarding. The patient was intubated for respiratory distress, given intravenous fluids, and started on dopamine at a rate of 5 ␮g/kg/min. Blood cultures were drawn. In the process of obtaining urine for analysis and culture, 200 cc of purulent material was obtained per Foley catheter. The white blood count was 29,700/mm3. Chest X-ray study demonstrated a right lower lobe infiltrate.

Ceftazidime, vancomycin, and gentamicin were administered, and the patient was admitted to the Medical Intensive Care Unit. He succumbed within 48 h. A bacteriuria screen was presumptively positive, but there was no growth on culture confirmation. Blood cultures, however, were positive for Proteus mirabilis sensitive to TMP/SMZ.

DISCUSSION These two patients demonstrate typical findings of pyocystis. Symptoms may include fever, suprapubic pain or distention, abdominal pain, foul smelling urethral discharge, or sepsis. Anuric patients are often believed incapable of acquiring a urinary pathogen, hence, the urinary tract may be mistakenly discounted as a possible source of sepsis (4). Urethral discharge may be misinterpreted as vaginal discharge as in our first patient. The misdiagnosis could have been prevented had we recognized that the inability to tolerate catheterization for pelvic ultrasound was secondary to pyocystis. In such cases, urethral catheterization will expose the pathology to be from the bladder as opposed to a gynecologic condition (2). Infectious complications are seen frequently in endstage renal failure patients on dialysis, and the urinary tract is noted to be the source of bacteremia in 6 –20% of them (8,9). There are limited data on the incidence of UTIs in end-stage renal disease, but it seems to be in the range of 10 –15% (10). The spectrum ranges from simple cystitis to pyelonephritis, pyocystis, pyronephrosis, and perinephric abscess. Pyocystis complicates neurogenic bladders treated by ureteroileostomy in 19 –30% of patients, although the incidence has been reported as high as 67% (1–3,5–7). The incidence of pyocystis in renal failure is unknown. The pathogenesis of pyocystis is unclear. It is known that secretions collect in the nonfunctioning bladder. Postulated mechanisms for secretion accumulation include mucosal transfer of ions and water across the bladder epithelium; prostatic secretions by retrograde ejaculation in men; and decomposed, liquefied bladder epithelial cells (11,12). When secretions become infected, pyocystis ensues because the bladder does not have the stimulus of urine to cause contraction and emptying (13). The condition is more common in bladders that also have a component of outlet obstruction, as seen in urethral strictures, bladder neck obstruction, or prostatic enlargement (12). Pyocystis is also more common in women because of the short length of the urethra predisposing them to UTI in general (13). Common organisms that cause pyocystis are E. coli, P. mirabilis, P. aeruginosa, and Enterococcus, but S.

Pyocystis

marcescens, Streptococcus sp., and mixed flora can also be found. P. mirabilis is an organism that often causes UTI, especially in patients with Foley catheters. It has also been implicated in the production of pyocystis in susceptible patients (3). Our second patient’s blood cultures demonstrated P. mirabilis and, because the lung would be a highly unusual primary site for this type of infection, we concluded that the initial infective source was the bladder, despite the negative urine culture. When pyocystis is suspected in the anuric patient, or in the patient with outflow obstruction, catheterization is required for diagnosis (4,14,15). If the patient is capable of urinating even a few milliliters a day, a clean catch specimen may be diagnostic for UTI (10). However, the secretions found in pyocystis may be so viscid that catheterization may be required even in oliguric patients. One caution is that a minicatheter is unsuitable because of the small caliber of the catheter lumen and the tenacious nature of the purulent discharge. The importance of recognizing pyocystis is that the management differs from uncomplicated cystitis. As in all abscesses, the pus must be adequately drained. This is accomplished by repeated catheterizations or the placement of an indwelling catheter and irrigation (1,2,4,11,15). Historically, chemical agents, such as heated isotonic saline, dilute acetic acid, silver nitrate, and nitrofurazone, have been used (1,2). The current standard of care is irrigation repeated as needed and the instillation and retention of intravesical antibiotics. With an impaired ability to filter, transport, and concentrate, renal failure patients may not be able to achieve optimal urinary antibiotic levels despite satisfactory serum levels (16). Additionally, it is well accepted that abscesses, in general, have poor blood supplies and require drainage for eradication of the infection. Because it can be difficult to identify an organism in a partially treated infection, we postulate that the TMP/SMZ, which both of our patients received, was sufficient to prevent growth in culture but not adequate to eliminate the infection. Oral antibiotics are not considered appropriate therapy for pyocystis. Parenteral antibiotics covering Gram-negative organisms should be administered to manage possible concomitant bacteremia. If the patient is not already afflicted

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prior to treatment, catheterization and irrigation of the bladder may induce bacteremia. Surgical intervention, such as percutaneous suprapubic cystostomy, vaginal or perineal vesicostomy, or cystectomy, may be indicated for resistant or recurrent pyocystis (1). Septicemia is commonly a complication of UTI in chronic renal failure patients (14). In the renal failure patient who manifests fever, leukocytosis, sepsis without obvious source, or with symptoms referable to the genitourinary tract, the nonfunctioning bladder should be catheterized to rule out pyocystis.

REFERENCES 1. Tung GA, Papanicolaou N. Pyocystis with urethral obstruction: percutaneous cystostomy as an alternative to surgery. Can Assoc Radiol J 1990;41:350 –2. 2. Guerrier K, Albert DJ, Persky L. Experiences with pyocystis. Arch Surg 1971;103:63–5. 3. Eigner EB, Freiha FS. The fate of the remaining bladder following supravesical diversion. J Urol 1990;144:31–3. 4. Lees JA, Falk RM, Stone WJ, et al. Pyocystis, pyonephrosis and perinephric abscess in end stage renal disease. J Urol 1985;134: 716 –9. 5. Popli S, Daugirdas JT, Ing TS, et al. Pyocystis in a renal transplant recipient with a defunctionalized bladder. Am J Nephrol 1985;5: 431–2. 6. Parra RO, Andrus CH, Jones JP, et al. Laparoscopic cystectomy: initial report on a new treatment for the retained bladder. J Urol 1992;148:1140 – 4. 7. Singh G, Wilkinson JM, Thomas DG. Supravesical diversion for incontinence: a long-term follow-up. Br J Urol 1997;79:348 –53. 8. Keane WF, Shapiro WF, Raij L. Incidence and type of infections in 445 chronic hemodialysis patients. Trans Am Soc Artif Intern Organs 1977;23:41–7. 9. Nsouli KA, Lazarus JM, Schoenbaum SC, et al. Bacteremic infection in hemodialysis. Arch Intern Med 1979;139:1255– 8. 10. Rault R. Symptomatic urinary tract infections in patients on maintenance hemodialysis. Nephron 1984;37:82– 4. 11. Ray P, Taguchi Y, MacKinnon KJ. The pyocystis syndrome. Br J Urol 1971;43:583–5. 12. Stewart WW, Cass AS, Ireland GW. Experience with pyocystis following intestinal conduit urinary diversion. J Urol 1973;109: 375– 6. 13. Weinberg RW. Pyocystis. J Urol 1977;117:798 –9. 14. Montgomerie JZ, Kalmanson GM, Guze LB. Renal failure and infection. Medicine 1968;47:1–32. 15. Daugirdas JT, Ing TS. Handbook of dialysis. Boston, MA: Little, Brown and Co.; 1994:640 –1. 16. Brenner BM, Stein JH. Chronic Renal Failure. New York: Churchill Livingstone, 1981;313.