Emphysematous cystitis due to Klebsiella pneumoniae

"Beyond the Bladder: Exploring the Intricacies of Emphysematous Cystitis and Its Surprising Associations"

Emphysematous cystitis is defined by the presence of air within the bladder wall or lumen in imaging studies with increased incidence in elderly women and diabetics. It is a result of gas-forming organisms like Klebsiella and E. coli but can be caused by fungi such as Candida and Aspergillus as well with a wide spectrum of clinical presentations. In this article, we present a case of a 77-year-old female with diabetes mellitus who presented to the hospital with a chief complaint of left lower quadrant abdominal pain. Abdominal imaging revealed emphysematous cystitis, paraspinal abscess, and air in the thoracic and lumbar vertebrae. Laboratory results showed leukocytosis, lactic acidosis, and urinalysis significant for urinary tract infection but no positive urine or blood cultures. The patient was admitted to the intensive care unit for septic shock and was treated with mechanical ventilation, vasopressor support, and prompt antimicrobial therapy following which the requirement of vasopressors ceased on the third day of admission. The decision was then made by the family to pursue hospice care, following which mechanical ventilation was discontinued and the patient transferred to inpatient hospice. With this case report, we aim to add to the existing literature regarding the spread of intra-abdominal infections and go over a brief review of the currently available literature. From our review, we would like to conclude that the presence of pneumoracchis, especially in the setting of an intra-abdominal infection, is a poor prognostic marker, and timely diagnosis and treatment of potential causes are required to reduce mortality.

Emphysematous cystitis as a potential marker of severe Crohn's disease

Background

Emphysematous cystitis (EC) is characterized by the presence of air within the bladder wall, often a complication of urinary tract infection (UTI) by gas-producing organisms. However, EC has also been reported in the setting of infectious colitis suggesting an alternate etiology. We report a rare case of EC in the setting of severe Crohn’s colitis with no clinical evidence of UTI.

Case presentation

A 43-year old female presented with a 2-month history of bloody diarrhea consisting of 8–12 bowel movements a day, weight loss of 10 kg and peripheral edema. She also had multiple ulcerated lesions on her abdominal wall and in the perianal region. Initial CT scan was significant for pancolitis, anasarca and EC. The follow-up CT cystogram, flexible cystoscopy and pelvic MRI confirmed the diagnosis of EC and ruled out any fistulous tracts in the pelvis including enterovesical/colovesical fistula. The patient did not report any urinary symptoms and the urinalysis was within normal limits. An extensive infectious workup was negative. Despite the paucity of infectious findings, the EC was empirically treated with an intravenous third-generation cephalosporin. Colonoscopy was significant for multiple ulcerated and hyperemic areas with pseudopolyps all throughout the right, transverse and left colon. Biopsies confirmed Crohn’s colitis with no evidence of granulomata or dysplasia. Immunohistochemistry was negative for CMV. The perianal and abdominal wall lesions were suspected to be pyoderma gangrenosum although biopsies were equivocal. The colitis was initially treated with intravenous steroids followed by biologic therapy with Infliximab. Despite appropriate escalation of therapies, the patient developed colonic perforation requiring subtotal colectomy.

Conclusion

This is a rare case of EC in a patient with severe Crohn’s colitis. There was no evidence of urinary tract infection or fistulising disease. According to our review, this is the first reported incident of EC in a patient with inflammatory bowel disease without any prior intra-abdominal surgeries. While active Crohn’s disease alone is a critical illness, we conclude that concomitant EC may be a poor prognostic factor.

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.