Hospital: Hospital Univeritario de Getafe, Hospital Universitario de Getafe.
Aut@r o Autores: V. San Martin Luque, E. Escudero Romo, G. Ugena Diaz, G. Diaz Ibero, I. Cedrun Sitges.
We present a case of a 50-year-old woman with history of severe COPD, pulmonary hypertension, Plummer-Vinson syndrome and squamous cell carcinoma of the esophagus in remission. She presented to the emergency room with two days of mesogastric abdominal pain associated with asthenia, nausea and fever up to 39ºC. On admission presented hematuric urine associated with leukocytosis and acute phase reactant elevation. She evolves rapidly with hypotension, decreased level of consciousness and peripheral hypoperfusion. Because of her bad clinical condition and unclear diagnosis an abdominal CT was performed, revealing air within the bladder wall, surrounding the urinary catheter and through the paravesical/Retzius space, associated with enhancement of the the urothelium of the renal pelvis and left ureter.
The CT findings were indicative of emphysematous cystitis and urine culture was positive for Klebsiella pneumoniae. The patient was treated with 10 days of amoxicillinclavulanate showing clinical and radiological improvement at the end of the treatment. Emphysematous cystitis is a rare and potentially fatal urinary tract infección, characterized by the presence of gas in the bladder wall and/or lumen that can be visualized on a plain abdominal film, or most frequently on computed tomography (CT). Clinically it may present as uncomplicated cystitis, but may also have unusual clinical presentation with diffuse abdominal pain and/or sepsis. Pneumaturia has been described as a characteristic clinical finding but can be difficult to identify, therefore the image findings are usually necessary to make a diagnosis. Occurs mainly in diabetic middle age women but may also affects non-diabetic patients. Other risk factors include immunodeficiency, uropathy, neurogenic bladder, and recurrent UTI. One of the hypothesis of the pathogenesis in non-diabetics patients is that the tissue proteins and urinary lactulose serve as substrate, similar to what happens with glucose in diabetics. E. coli and K. pneumonia have been described as the most common pathogens, followed by Enterococci. Specific antibiotic therapy is the first linetreatment. Surgical management is reserve to cases with poor response to antibiotic treatment and/or associated complications. Failure to recognize this condition in early stages, increases the associated mortality rate by up to 10%.
Despite being infrequent, emphysematous cystitis can be potentially fatal without proper diagnosis and early treatment. In patients with urinary tract infection the CT scan may be consider in patients with rapid clinical deterioration or poor response to antibiotic therapy, where a complication may be suspected. Characteristics imaging findings, most frequently seen on CT, are necessary to make the right diagnosis.
- Grupper M, Kravtsov A, Potasman I. Emphysematous cystitis: illustrative case report and review of the literature. Medicine. 2007,86:47–53. - Eken A, Alma E. Emphysematous cystitis: The role of CT imaging and appropriate treatment. Can Urol Assoc J. 201