Eosinophilic cystitis in a child presenting with a bladder mass

A rare case of eosinophilic cystitis involving the inside and outside of the urinary bladder associated with an infected urachal cyst

BACKGROUND

Eosinophilic cystitis is a rare inflammatory disease of the bladder characterized by eosinophilic infiltration of the bladder wall. Most Eosinophilic cystitis cases present with mucosal lesions of the urinary bladder. We present a very rare case of large mass-forming eosinophilic cystitis, involving the inside and outside of the bladder associated with an infected urachal cyst.

CASE PRESENTATION

A 59-year-old man presented with gross hematuria, fever, dysuria, and suprapubic pain. Computed tomography showed a heterogeneously enhancing mass that measured 7.6 cm × 4 cm located on the anterosuperior portion of the bladder with an internal fluid collection. Cystoscopy revealed a raspberry-like mass lesion on the bladder dome. Transurethral resection of the bladder was initially performed. The mass lesion protruding from inside the bladder was removed, and pus-like fluid was drained. The pathologic diagnosis was eosinophilic cystitis. Follow-up computed tomography showed a remnant mass outside the bladder and urachal cyst. To eliminate the remnant lesion, robot-assisted partial cystectomy was performed. The patient showed no evidence of recurrent disease on follow-up cystoscopy and computed tomography for up to 2 years.

CONCLUSIONS

Clinicians should consider the possibility of eosinophilic cystitis in patients who present with hematuria, fever, and suprapubic pain and have both intravesical and extravesical masses.

Eosinophilic cystitis in children: A case report

The aim of the present case report was to investigate the clinical features, pathological examination and treatment of eosinophilic cystitis (EC) in children. Two cases of EC were reported and reviewed from January 2016 to March 2017. Case 1 (male; 6 years old) had intermittent hematuria, frequent urination, urgent urination, difficulty in urination and abdominal pain. Case 2 (male; 7 years old) had frequent urination, urgent urination, urinary pain, dysuria and suprapubic pain with no hematuria. One patient had a history of allergies and both patients underwent a cystoscope biopsy. Blood eosinophils were clearly increased and a bone marrow biopsy examination revealed that marrow eosinophils were also increased in both cases. The urine culture results were negative. Ultrasonography and computed tomography revealed uneven thickening of the bladder wall and diffusive mucosal lesions. Cystoscopy revealed that the bladder volume became smaller and the mucosa at the bladder floor and neck was red. Lesions were biopsied through the urethra and the following characteristics were observed: Congestion and edema of the bladder mucosa, infiltration of the blood vessels and eosinophils in the muscular layer, accompanied by focal muscle necrosis. Patient 1 was administered anti-inflammatory and cetirizine hydrochloride treatments, followed by 6 weeks of prednisone dose-reduction therapy. Patient 2 was administered antibiotics and cetirizine hydrochloride. Following 6-month follow-ups, abnormal voiding symptoms had disappeared in each case. Ultrasonography and computed tomography revealed no bladder wall thickening or space-occupying lesions. EC in children is rare and easily misdiagnosed as nonspecific bladder inflammation or bladder occupying lesions. Cystoscopy and biopsy are necessary to diagnose EC and conservative treatments with anti-inflammatory, anti-allergic and cortical hormone nonspecific treatments are suggested.

Case: Eosinophilic cystitis presenting as a bladder mass in an 11-year-old girl

We report the case of an 11-year-old girl who presented with acute urinary retention and microscopic hematuria. Pelvic imaging revealed a bladder mass for which sarcoma was initially suspected. Surgical biopsies revealed a massive eosinophilic infiltration of the submucosa confirming a diagnosis of eosinophilic cystitis. Clinical evolution was favourable without treatment. Eosinophilic cystitis prognosis is usually benign, but rare severe complications, such as complete bladder fibrosis requiring bladder augmentation or cystectomy, may occur.

Mass Forming Eosinophilic Cystitis in Pediatric Patients

Eosinophilic cystitis (EC) is an uncommon inflammatory disorder of uncertain etiology that has been described in adult and pediatric populations. We describe 3 recent cases of EC that presented as a mass lesion in pediatric patients from the New England region of the United States. All patients were initially suspected to have a malignancy, and biopsy was performed, which ultimately led to the diagnosis of EC. We propose the use of eosinophil density of >25 eosinophils per high-power field and myocyte degeneration as supportive histopathologic features to make this diagnosis. It is of utmost importance to consider EC in the differential diagnosis when approaching a pediatric patient with a bladder mass.

How should eosinophilic cystitis be treated in patients with chronic granulomatous disease?

BACKGROUND

Chronic granulomatous disease (CGD) is a primary immunodeficiency resulting from the absence or malfunction of oxidative mechanism in phagocytic cells. The disease is due to a mutation in one of four genes that encode subunits of the nicotinamide adenine dinucleotide phosphate (NADPH) oxidase complex. Affected patients experience severe infections and granuloma formation due to exuberant inflammatory responses. Some evidence suggests that eosinophilic cystitis (EC) is included in the spectrum of inflammatory manifestations. EC is an inflammatory disease, rare in childhood, which may require different, nonstandardized therapeutic approaches, ranging from antihistamines to cyclosporine.

CASE-DIAGNOSIS/TREATMENT

Herein we describe the cases of two CGD patients with CGD who experienced EC during hospitalization for a severe infection.

CONCLUSIONS

EC in immunocompetent children seems to have a self-limiting course, unlike in CGD patients, in whom it presents a prolonged and recurrent course. We focus on the effective therapy administered to our patients with CGD and review the corresponding literature.

Eosinophilic cystitis: three cases, and a review over 10 years

Eosinophilic cystitis (EC) is a rare disease. We describe three cases, where presentations of the disease are similar. To highlight probable causes of the disease, symptoms, clinical findings and treatment modalities, we reviewed 56 cases over a 10-year period. The most common symptoms were frequency, dysuria, urgency, pain and haematuria. Common clinical findings were presence of bladder mass, peripheral eosinophilia and thickened bladder wall. A variety of medical treatments were used, most frequently steroids, antibiotics and antihistamines. Recurrence occurred in patients on tapering or discontinuing prednisone, among other reasons. There is no consensus about the treatment of EC, but In light of our findings in this review, the treatment of choice in our department will be tapered prednisone over 6-8 weeks in combination with antihistamine.

Eosinophilic cystitis in the pediatric population: a case series and review of the literature

PURPOSE

Eosinophilic cystitis is a rarely seen condition in the pediatric population with indistinct symptomatology and non-standardized treatment protocols. We review our experience of treating patients with this condition.

MATERIALS AND METHODS

We retrospectively reviewed the records of four patients from a single institution who have been diagnosed and treated for eosinophilic cystitis. In addition, the literature was reviewed for cases of pediatric eosinophilic cystitis. Our patients were added and compared to this cohort.

RESULTS

Our patients included 3 females and 1 male who range in age from 5 days to 18 years (5 days, 1 month, 7 years, 18 years). Both of the infants presented with a suprapubic mass and bilateral hydroureteronephrosis. The two older patients both had dysuria while the 18 yo also complained of fatigue, flank pain, and hematuria. Only 2 of the 4 patients were found to have significant peripheral eosinophilia and only one patient had eosinophiluria. All of the patients were diagnosed via cystourethroscopy with biopsy. Treatment in each case consisted of a combination of steroids, antihistamines, and antibiotics.

CONCLUSIONS

The presentation of eosinophilic cystitis is varied and diagnosis requires a high index of suspicion. Cystourethroscopy with biopsy is essential to establish the diagnosis as there is no typical appearance of the lesions or presenting signs/symptoms. Most cases of eosinophilic cystitis are responsive to medical therapy although in some cases recurrence may be noted.

Eosinophilic cystitis: a rare cause of hematuria in children

A 7-year-old boy presented with a history of acute onset of hematuria, dysuria, and suprapubic pain. Urine routine and microscopy showed 40-45 red cells/high power field. Urine culture was sterile. Radiological investigations showed a focal mucosal lesion with bladder wall thickening. Biopsy of the lesion revealed an edematous mucosa with florid infiltration by eosinophils into the muscularis propria with focal areas of myonecrosis. He was diagnosed as a case of eosinophilic cystitis. The patient received 6 weeks of tapered prednisone therapy. He was asymptomatic on followup.

[Eosinophilic cystitis in children]

Eosinophilic cystitis (EC) is a rare disease that frequently suggests a bladder tumour at presentation. It affects both children and adults and its pathophysiology remains unclear. EC usually shows a benign course, but serious complications can occur and relapsing forms have been described. It has rarely been reported in children and therefore, might be poorly known by physicians and underdiagnosed. We report a case that differs from other observations by its unusually rapid resolution, and review the literature on EC's diagnosis, treatment, and course in children.

Acute urinary retention in a 7-year-old girl: an unusual complication of cytomegalovirus cystitis

Acute urinary retention in children is rare. There are a variety of causes about the disease. We report a case of a 7-year-old girl with acute urinary retention and hematuria. Pelvic sonogram revealed an isoechoic mass in the urinary bladder that appeared as a lobulated filling defect over the bladder neck on intravenous urography and computed tomography studies. The surgical specimen from cystoscopic examination showed reactive changes on pathologic analysis. Cytomegalovirus was isolated from urine culture. The girl recovered after supportive treatment.

MR imaging findings of eosinophilic cystitis in an 8-year-old girl

Eosinophilic cystitis is a rare inflammatory condition of the urinary bladder of unknown aetiology and characterized by eosinophilic infiltration of the bladder wall. We report the unique MR findings of eosinophilic cystitis in an 8-year-old girl who presented with peripheral eosinophilia. MR imaging revealed smooth and nearly circumferential thickening of the bladder wall showing distinct low signal intensity on T2-weighted images, which may histologically represent high cellularity due to massive eosinophilic infiltration.

Clinical manifestations and functional outcomes in children with eosinophilic cystitis

PURPOSE

Eosinophilic cystitis is a rare disorder, with fewer than 30 pediatric cases reported in the literature. We describe our experience with pediatric eosinophilic cystitis during a 20-year period.

MATERIALS AND METHODS

Four children referred to our institution were subsequently diagnosed with eosinophilic cystitis between 1984 and 2004. A retrospective chart review was performed to assess clinical presentation, diagnosis, treatment and outcomes.

RESULTS

Mean patient age at presentation was 10.8 years (range 5 to 18) and male-to-female ratio was 3:1. All 4 patients presented with irritative urinary symptoms, including 3 with dysuria and/or gross hematuria and 2 with urinary frequency, lower abdominal pain and/or a concomitant urinary tract infection. Allergic diseases (asthma, allergic rhinitis, etc) were present in 3 patients, and a formal allergen skin test was positive in 2 of those tested. A bladder mass mimicking malignancy was documented in 2 patients. Three patients had symptom resolution with conservative treatment, while 1 had development of an unremitting tumefactive process that eventually required partial cystectomy and bladder augmentation.

CONCLUSIONS

Eosinophilic cystitis is a rare condition with a wide range of clinical manifestations. Children can present with a bladder mass mimicking sarcoma, underscoring the need for biopsy before diagnosis and treatment of a presumed oncological process. The condition usually follows a benign course, although unremitting progression remains a possibility.

Eosinophilic cystitis: successful long-term treatment with montelukast sodium

We report a rare case of eosinophilic cystitis in a 6-year-old boy who presented with irritative voiding symptoms, peripheral eosinophilia, and a bladder mass initially visualized on ultrasonography. Cystoscopy and transurethral biopsy confirmed the diagnosis. Complete resolution of his symptoms occurred within 1 week of corticosteroid use and the x-ray findings improved within 6 weeks. At 6 months of follow-up, the patient continued to require a leukotriene receptor antagonist (montelukast sodium) despite several attempts to discontinue its use. We propose that eosinophilic cystitis in children who present with peripheral eosinophilia will often require long-term treatment.