Emphysematous urinary tract infections: diagnosis, treatment and survival (case review series)

Uncommon Haemorrhagic Cystitis of Infectious Origin: A Narrative Review for Urologists

Purpose

Haemorrhagic cystitis may be due to different etiologies with infectious diseases representing an insidious cause to diagnose. The aim of this narrative review is to provide a comprehensive overview of less common but difficult-to-diagnose causes of infectious haemorrhagic cystitis of bacterial, mycobacterial, and parasitic origin, Moreover, we highlight possible diagnostic tools and currently available treatment options in order to give an updated tool for urologists to use in daily practice.

Patients and Methods

The search engine PubMed was used to select peer-reviewed articles published from 1/Jan/2010 to 31/Aug/2022.

Results

Bacteria, fungal, TB and schistosomiasis are uncommon causes of haemorrhagic cystitis burdened by high morbidity, especially if not promptly diagnosed.

Conclusion

Because haemorrhagic cystitis ranges in severity from mild dysuria associated with pelvic discomfort to severe life-threatening haemorrhage, punctual diagnosis, and immediate treatment are essential to avoid further complications.

Emphysematous cystitis, iliopsoas abscess, and pneumorrhachis in an elderly woman: a case report

BACKGROUND

Emphysematous cystitis is a well-described life threatening complication of urinary tract infection, most commonly seen in patients with diabetes and typically caused by gas forming bacterial or fungal pathogens. Pneumorrhachis is the rare finding of gas within the spinal canal, most commonly reported in the context of cerebrospinal fluid leakage secondary to trauma or spinal instrumentation. To our knowledge there is only one other reported case of pneumorrhachis in the setting of emphysematous cystitis.

CASE PRESENTATION

This is a single case report of pneumorrhachis in the setting of emphysematous cystitis. An 82-year-old Asian female patient originally from East Asia, with no prior medical history besides hypertension, presented to hospital with a chief complaint of acute on chronic neck pain and functional decline. Examination revealed nonspecific neurosensory deficits and suprapubic tenderness. Laboratory investigations demonstrated leukocytosis and extended-spectrum beta-lactamase containing Escherichia coli bacteremia and bacteriuria. Computed tomography showed emphysematous cystitis with widespread gas within the cervical and lumbar spinal canal, as well as multiple gas-containing soft tissue collections in the bilateral psoas muscles and paraspinal soft tissues. Despite prompt antimicrobial therapy the patient passed away within 48 hours from septic shock.

CONCLUSIONS

Our case adds to a growing body of literature showing that the spread of air to distant sites, including the spine, may be a poor prognostic indicator in patients with gangrenous intraabdominal infections. This report highlights the importance of recognizing the causes and presentation of pneumorrhachis to facilitate early diagnosis and treatment of potentially life threatening and treatable causes.

Emphysematous cystitis: an incidental finding with varying outcomes

Emphysematous cystitis (EC) is a rare severe urinary tract infection characterised by pockets of air in and around the urinary bladder wall caused by gas-forming organisms. Common predisposing factors are chronic infection, immunosuppression, diabetes and neurogenic bladder. The presentation may vary from mild illness to severe life-threatening cystitis. We report two cases of incidental detection of EC diagnosed on imaging for the evaluation of unrelated symptoms. Although asymptomatic, this lethal disease still warrants prompt recognition and treatment with broad-spectrum antibiotics and urinary bladder drainage to prevent severe morbidity and mortality.

Fatal systemic emphysematous infection caused by Klebsiella pneumoniae: A case report

BACKGROUND

Systemic emphysematous infection caused by Klebsiella pneumoniae (K. pneumoniae) is a rare but severe infection which can be lethal if the diagnosis is delayed.

CASE SUMMARY

We report a rare case of systemic emphysematous infection via hematogenous dissemination from a liver abscess caused by K. pneumoniae, complicated by multiple organ dysfunction syndrome, septic shock, bacteremia, emphysematous cystitis, prostate and left seminal vesicle abscesses in a diabetic patient. The patient simultaneously presented with spontaneous pneumoperitoneum secondary to rupture of the emphysematous liver abscess. His condition after admission deteriorated rapidly and he died within a short period. This disease is a great challenge for the clinician as K. pneumoniae can cause multifocal emphysematous infections and fulminant septic shock. Pneumoperitoneum following spontaneous rupture of the liver abscess can result in intra-abdominal sepsis that further increases mortality rate. Moreover, appropriate site-specific intervention and adequate drainage of numerous emphysematous liver lesions are difficult.

CONCLUSION

Early diagnosis followed by efficient antibiotic therapy and surgical management are essential for systemic emphysematous infection.

Clinical Outcomes and Risk Factor Analysis of Patients Presenting with Emphysematous Cystitis: A 15-Year Retrospective Multicenter Study

Background and objectives: To investigate the risk factors for emphysematous cystitis (EC) compared to those of acute cystitis (AC) to increase clinicians awareness of the possibility for the aggravation of patient status. Materials and methods: We retrospectively reviewed a total of 54 patients who were hospitalized with a diagnosis of EC by abdominal computed tomography (CT) scan from 2006 to 2020. The control group included 92 patients who were hospitalized for the treatment of AC in the same period. We sought to identify the clinical features and predisposing diseases, such as age, sex, diabetes mellitus (DM), hypertension (HTN), cerebrovascular accident (CVA), chronic kidney disease (CKD), neurogenic bladder (NB), history of urinary tract infection (UTI), and emphysematous pyelonephritis (EPN), that were associated with the development of EC. Results: The median (interquartile range (IQR)) age of the patients with EC was older than that of the patients with AC (78.5 (15.3) years (range: 52-100) vs. 70.0 (26.5) years (range: 28-97 years)). Sepsis and mortality occurred only in the EC group (48.1% and 11.1%, respectively). The univariate analysis of predisposing factors revealed that age, DM, HTN, CVA, CKD, and NB were significantly associated with EC. In the multivariate analysis, DM (OR, 6.251; 95% CI, 2.254-17.250; p < 0.001), CKD (OR, 18.439; 95% CI, 3.421-99.404; p = 0.001), NB (OR, 7.374; 95% CI, 1.993-27.285; p = 0.003) were associated with EC. Conclusions: The results of this study revealed that DM, CKD, and NB were significant risk factors for EC. The tendency toward sepsis and high mortality underscore the need for careful observation while treating patients with EC with the risk noted above.

An Unusual Case of Complicated Urinary Tract Infection: Emphysematous Cystitis

Emphysematous cystitis (EC) is a rare disease of the urinary bladder, caused by gas-forming bacteria, which can become life-threatening without appropriate evaluation. This report describes the case of a 77-year-old male with uncontrolled diabetes mellitus type II, who presented with suprapubic pain associated with frequency, urgency, dysuria, and gross hematuria involving the passage of clots. A review of systems was negative for weight changes, history of malignancy, urolithiasis, exposure to industrial chemicals, history of gastrointestinal tract disease, radiation therapy, and trauma. The patient was febrile upon admission. Laboratory findings were significant for lactate (2.7 mg/dl), and leukocytosis (28,100/uL). Computed tomography of the abdomen and pelvis showed dense material and air within the bladder, bilateral hydronephrosis, and hydroureter. He was managed with ceftriaxone (2 gm every 24 hours for 14 days), and a urinary catheter. EC should be considered as a differential diagnosis in diabetes mellitus patients presenting with hematuria, because knowledge of this rare finding may lead to early diagnosis and appropriate management.

[SUCCESSFUL TREATMENT OF SEVERE EMPHYSEMATOUS CYSTITIS USING RETROPENITONEAL DRAINAGE: A CASE REPORT]

Emphysematous cystitis is a rare disease involving infection caused by gas-producing bacteria is characterized by air storage in the bladder wall and lumen. Approximately 90% of the affected cases are treated using medical therapy alone, and approximately 10% require combined surgical treatment. Here we report a case of emphysematous cystitis with septic shock that could be treated using multimodal therapy with retroperitoneal drainage. A 76-year-old woman was hospitalized at a nearby hospital owing to lumbar compression fracture. She was transferred to our hospital owing to altered consciousness and low blood pressure. She was diagnosed with emphysematous cystitis, and conservative treatment was performed using an indwelling bladder catheter and by administering antibiotics or vasopressors. The patient had septic shock; hence, retroperitoneal drainage was performed. After surgery, the patient's general condition improved. In this study, we review the characteristics of five cases of emphysematous cystitis requiring surgical treatment in Japan.

A case of bilateral emphysematous pyelonephritis caused by Candida albicans

Emphysematous pyelonephritis (EPN) is a life-threatening renal infection characterized by the formation of gas within the renal parenchyma and collecting duct system, as well as perinephric tissues. We herein report a case of bilateral EPN accompanied by the urinary tract infection caused by spherical growth of Candida albicans in a patient with underlying diabetes mellitus and prostate cancer. The diagnosis was assisted by computed tomography, urography, and gram staining. Despite immediate percutaneous catheter drainage and a 4-week course of antifungal treatment, the C. albicans infection was refractory, as indicated by continuous isolation from the urine, and the patient eventually died. A local autopsy of urinary organs revealed C. albicans in the renal tissue. EPN caused by Candida species frequently occurs in men, and almost all cases have underlying poorly controlled diabetes. This condition is subject to delayed diagnosis, which may lead to extended disease and high mortality. Candida species should be considered as causative microorganism for refractory EPN in patients with poorly controlled diabetes who are receiving antibiotic treatment. Gram staining may contribute to an early diagnosis of EPN caused by Candida species, which may require long-term antifungal therapy.

Emphysematous pyelonephritis: Case report and literature overview

INTRODUCTION

Emphysematous pyelonephritis is a rare necrotizing infection of the kidney with a poor prognosis. If it occurs in patients with a reduced general condition, this infection is life threatening. Early diagnosis is made by computed tomography. Treatment options are drainage and intensive care or immediate nephrectomy in severe cases.

CASE DESCRIPTION

A 73-year-old woman in a poor general condition presented with a fulminant urosepsis. Computed tomography revealed an impressive abscess formation of the right kidney with free air retro and intraperitoneal. The diagnosis of emphysematous pyelonephritis was made. Besides septicemia, she had a multiorgan failure including kidney and liver function deterioration. Nephrectomy was performed immediately. The postoperative course was successful with a complete stabilization of the kidney and liver function and reconvalescence of the patient.

DISCUSSION

The widespread availability of imaging techniques leads to early diagnosis and a reduction of mortality of renal and periphrenic abscesses and even of emphysematous pyelonephritis. However, severe cases have a poor outcome and require aggressive and immediate therapy. Besides systemic antibiotic therapy and percutaneous and surgical drainage, radical nephrectomy is a viable therapy option and should be performed immediately in patients with several risk factors, poor prognosis, and extensive findings.

CONCLUSION

Radical nephrectomy being performed immediately seems to be the optimal management in patients with acute emphysematous nephritis and urosepsis.

Gas surrounding the urinary bladder in emphysematous cystitis

We report a rare case of emphysematous cystitis in a 66-year-old woman with a history of diabetes mellitus. The predisposition of diabetes mellitus and infection of gas-forming bacteria is considered to precede the manifestation of emphysematous cystitis. The present recommended diagnosis test is computed tomography, which have definite value in the evaluation of gas accumulation in bladder wall, or an air-fluid level in bladder.

Demonstrative Imaging of Emphysematous Cystitis

This case report presents an incidental finding of emphysematous cystitis on computed tomography (CT) scan done as part of evaluating abdominal pain in a 78 years old man with a history of metastatic thymus carcinoma.

A Rare Case of Pneumoureter: Emphysematous Pyelitis versus Emphysematous Pyelonephritis

Emphysematous pyelitis is a rare benign entity which is defined as isolated gas production in the pelvicalyceal system, ureters or in the urinary bladder as a consequence of acute bacterial renal infection. In this case report we present a case with no prior medical history of diabetes or urinary obstruction who presented with uncontrolled hyperglycaemia for the first time associated with emphysematous pyelonephritis. Further, the imaging differences between emphysematous pyelonephritis (EPN) and emphysematous pyelitis (EP) has been discussed along with the approach and their management.

Emphysematous cystitis presenting as severe confusion and abdominal pain: two case reports

Introduction

Emphysematous cystitis is a very rare complicated urinary tract infection characterized by air in the bladder wall.

Case presentation

We report two clinical cases of emphysematous cystitis of an 83-year-old Caucasian woman with diabetes mellitus and a 78-year-old Caucasian man with no past medical history. They presented with severe confusion and abdominal distension. Emphysematous cystitis was diagnosed in time with a thorough physical examination, urine analysis and computed tomography. The patients were successfully treated with antibiotic therapy and bladder drainage.

Conclusion

This rare disorder should be recognized in time and treated properly to guarantee survival.

The effect of diabetes mellitus on chronic rhinosinusitis and sinus surgery outcome

BACKGROUND

Patients with diabetes mellitus (DM) are known to be prone to infection. However, the association between diabetes and chronic rhinosinusitis (CRS) has not been well studied. We sought to determine the effects of DM on CRS culture results and quality of life (QOL) after functional endoscopic sinus surgery (FESS).

METHODS

We conducted a retrospective cohort study. Adult CRS patients undergoing FESS were recruited from October 1, 2007 to December 31, 2011. Patient demographics, comorbidities, medication use, and Lund-Mackay CT scores were collected prior to FESS. Intraoperative culture was obtained. Preoperative and 1-month, 3-month, and 6-month postoperative QOL was measured by scores on the 22-item Sinonasal Outcome Test (SNOT-22). A mixed effects model was performed for analysis.

RESULTS

Among the 376 CRS patients included, 19 patients (5.05%) had DM. Compared to non-DM patients, DM patients were significantly more likely to have Pseudomonas aeruginosa (26.32% vs 7.56%; p = 0.004) and Gram-negative rods (26.32% vs 8.96%; p = 0.013), but there was no significant difference in the prevalence of Staphylococcus aureus; DM patients were also significantly more likely to have nasal polyps and gastroesophageal reflux disease. Additionally, DM patients had significantly less improvement of postoperative SNOT-22 scores from baseline to 6-month follow-up than non-DM patients (adjusted mean = 11.14, 95% CI (0.14, 22.15), p = 0.047) after adjusting for all the other risk factors for CRS.

CONCLUSION

DM patients may be prone to Gram-negative bacterial sinus infections, and have significantly worse short-term postoperative QOL. Special postoperative care may need to be considered in CRS patients with DM.

Emphysematous cystitis: The role of CT imaging and appropriate treatment

Emphysematous cystitis is a relatively rare disease characterized by the presence of gas in the bladder wall and/or lumen. The primary risk factor is diabetes mellitus. Emphysematous cystitis should be considered in cases of urinary tract infections in diabetic patients with unusual presentations. Imaging studies are necessary to detect emphysematous cystitis. Accurate diagnosis of the disease and appropriate treatment typically results in a favourable prognosis and can improve the outcome. We present a case of emphysematous cystitis diagnosed by a computed tomography scan in a diabetic woman with poor glycemic control.

Emphysematous pyelonephritis: Time for a management plan with an evidence-based approach

INTRODUCTION

Emphysematous pyelonephritis (EPN) is a life-threatening necrotising kidney infection, but there is no consensus on the best management.

METHODS

We systematically reviewed previous articles published from 1980 to 2013 that included studies reporting on EPN, and applying the Cochrane guidelines, we conducted a meta-analysis of the results.

RESULTS

In all, 32 studies were included, with results for 628 patients (mean age 56.6 years, range 33.8-79.9). There were 462 women, outnumbering men by 3:1. Diabetes was present in 85% of the cases. Fevers and rigor (74.7%), pyuria (78.2%) and pain (70.4%) were the most common symptoms. Shock was associated with 54.4% of deaths while obstructive uropathy was associated with 15.1% of deaths. Computed tomography was diagnostic in all the cases. Percutaneous drainage (PCD) and medical management (MM) alone were associated with a significantly lower mortality rate than was emergency nephrectomy (EN), with an odds ratio (95% confidence interval) for PCD vs. EN of 3.13 (1.89-5.16; P < 0.001), for EN vs. MM of 2.84 (1.62-4.99; P = 0.001), and of 0.91 (0.53-1.56; P = 0.73, i.e., no difference) for PCD vs. MM. Open drainage also had a significantly lower mortality rate than EN, with a ratio of 0.12 (0.02-0.91; P < 0.04).

CONCLUSION

The overall mortality rate was ≈18%; shock was associated with a high mortality rate and therefore should be managed aggressively. PCD and MM were associated with significantly higher survival rates than EN, and therefore EN should only be considered if the patient does not improve despite other treatments.

Emphysematous Pyelonephritis-a Rare Surgical Emergency Presenting to the Physician: A Case Report and Literature Review

Emphysematous pyelonephritis is an acute necrotizing parenchymal and perirenal infection caused by gas-forming uropathogens. It is a rare condition, usually occurring in diabetic patients. Mortality rates in medically managed patients are as high as 70-90 %. It should be suspected in diabetic patients with urinary tract infections and worsening of renal function. CT scan is diagnostic and is the method of choice for diagnosis and follow-up. Both physicians and surgeons should be aware of this rare condition which might present to the physician as fulminant urinary tract infection in an uncontrolled diabetic patient, but which might warrant urgent surgical intervention by way of an emergency nephrectomy. We report a 60-year-old diabetic woman who presented with urinary infection and sepsis. Initially she was managed conservatively, but had to be taken up for emergency nephrectomy in view of her worsening condition. We review the clinical presentation, radiological diagnosis with characteristic CT scan pictures, and the management of this rare condition.

Risk factors of renal failure and severe complications in patients with emphysematous pyelonephritis-a single-center 15-year experience

INTRODUCTION

Emphysematous pyelonephritis (EPN) is a rare but severe infection of renal parenchyma. Risk factors of renal failure in patients survived from EPN are not clear.

METHODS

The authors retrospectively reviewed the patients with a diagnosis of EPN at Taipei Veterans General Hospital from January 1, 1995, to December 31, 2009. The authors analyzed the demographic, characteristics and the treatment modalities of those patients. The renal function of survivors after EPN episode had been followed for 1 year.

RESULTS

A total of 23 patients with a mean age of 62.8 ± 17.1 years were enrolled. Mean hospital duration was 31.8 ± 21.6 days. Fifteen (65.2%) patients had a history of diabetes mellitus. Mean serum HbA1c level among the diabetic patients was 11.7 ± 3.3. More than half of patients had Escherichia coli in culture. Eleven (47.8%) patients received antibiotic treatment alone. Twelve (52.2%) patients received the concurrent percutaneous drainage and antibiotics. The overall mortality rate was 8.6%. Shock, long hospital duration and the extensive classes of computed tomography image were correlated with poor outcome. A higher initial serum creatinine level (2.8 ± 1.4 versus 1.6 ± 0.8, P = 0.015) and receiving invasive therapy (67.7% versus 12.5%, P = 0.017) significantly contributed to chronic kidney disease in the follow-up. Shock is also an independent predictor of the poor outcome in those patients (P = 0.026).

CONCLUSIONS

In the current era, antibiotics alone provide a high success rate for the treatment of EPN. Invasive therapy is a predictor of development of chronic kidney disease. Initial resuscitation and antibiotic therapy are still the cornerstone and have the benefit of the preservation of renal function.

Infections in patients with diabetes mellitus: A review of pathogenesis

In general, infectious diseases are more frequent and/or serious in patients with diabetes mellitus, which potentially increases their morbimortality. The greater frequency of infections in diabetic patients is caused by the hyperglycemic environment that favors immune dysfunction (e.g., damage to the neutrophil function, depression of the antioxidant system, and humoral immunity), micro- and macro-angiopathies, neuropathy, decrease in the antibacterial activity of urine, gastrointestinal and urinary dysmotility, and greater number of medical interventions in these patients. The infections affect all organs and systems. Some of these problems are seen mostly in diabetic people, such as foot infections, malignant external otitis, rhinocerebral mucormycosis, and gangrenous cholecystitis. In addition to the increased morbidity, infectious processes may be the first manifestation of diabetes mellitus or the precipitating factors for complications inherent to the disease, such as diabetic ketoacidosis and hypoglycemia. Immunization with anti-pneumococcal and influenza vaccines is recommended to reduce hospitalizations, deaths, and medical expenses.

A case of emphysematous cystitis complicated with miliary tuberculosis

Background:

Emphysematous cystitis occurs mostly in diabetics with poor glycemic control or in immunocompromised patients. In most cases, diabetes mellitus correlates with the occurrence of emphysematous cystitis. The risk of relapse after tuberculosis cure or treatment completion is high among patients with diabetes mellitus.

Case Report:

A 64-year-old diabetic man suffering from high fever and lower abdominal pain was admitted to the emergency ward. Due to the results of radiographic examinations, he was diagnosed with an emphysematous cystitis. Although the emphysematous cystitis improved with urinary drainage and antibiotic therapy, the high fever recurred and respiratory symptoms appeared. This patient was diagnosed with a crisis of the pulmonary tuberculosis. He was started on the antituberculosis therapy, and he recovered.

Conclusions:

This is the first report of a case of emphysematous cystitis that was complicated with pulmonary tuberculosis.

Emphysematous cystitis: radiological diagnosis of complicated urinary tract infection

Emphysematous cystitis is an uncommon condition characterised by the presence of gas in the bladder. It is an infection caused by gas forming organisms, usually in elderly women with a background of diabetes mellitus. The presentation is variable, however with increasing use of imaging more cases are being diagnosed in asymptomatic patients. Routine cross-sectional imaging is not advocated for specific diagnosis but its role in accurate assessment of the severity of the condition cannot be overlooked. As the mode and duration of follow-up in incidentally detected cases has not been addressed in the literature, follow-up should be tailored individually depending upon the severity and response to treatment. We describe two such incidentally detected cases of emphysematous cystitis in elderly diabetic patients and present a review of the literature. The triad of treatment is adequate control of diabetes, antibiotics and bladder drainage. One patient died in the hospital, while the other underwent a flexible cystoscopy 6 weeks later which was normal.