Concurrent emphysematous cholecystitis, cystitis and pyelonephritis in a patient with diabetes type II

Clinical History

A 57-year-old woman with non-insulin-dependent diabetes presented to the emergency department complaining of weakness, nausea, mild fever, vomiting and diarrhoea during the last days. On clinical examination there were no signs of peritonism or associated jaundice but the patient was sensitive on pulsation of the right upper quadrant of the abdomen.

Imaging Findings

Plain X-ray of the abdomen showed gas in the wall of the gallbladder which raised the suspicion of emphysematous cholecystitis (Fig.1). Computed tomography of the abdomen with oral contrast was performed that showed an enlarged gallbladder with thickened wall containing intraluminal air, an air-fluid level within the gallbladder itself (Fig. 2) and a few gas bubbles within the intrahepatic bile ducts. No calculi were seen within the gallbladder at either CT or ultrasound (Fig. 3). Coincidentally an air-fluid level was revealed in the urinary bladder and gas bubbles in the bladder wall (Fig. 4), as well as air in the upper pole of the right kidney (Fig. 2). The patient was thus considered to have concurrent emphysematous infection of the urinary tract manifested as emphysematous pyelonephritis and emphysematous cystitis.

Discussion

The diagnosis of emphysematous pyelonephtitis, cystitis and emphysematous cholecystitis can be made on plain radiographs of the abdomen, ultrasonography or on Computed Tomography (CT). The diagnosis of emphysematous cholecystitis in our patient was initially made based on the plain X-ray of the abdomen that shows air in the gallbladder wall and the CT that followed confirmed our suspicion but also revealed concurrent infection of the urinary tract. Emphysematous infections of the abdomen are common in patients with diabetes mellitus and causative organisms usually are Escherichia coli, Staphylococcus aureus, Clostridium perfrigens, Nocardia and Candida albicans [1, 2]. Treatment strategies for the management of these disorders include control of blood glucose levels with appropriate monitoring of fluid, broad-spectrum antibiotics covering Gram-negative organisms and anaerobes, and surgery if appropriate. If there is no response 72–96 h after instituting antimicrobial therapy, nephrectomy and cholecystectomy should be performed [3]. Overall, it is important to underline that in gas-forming infections clinical outcome largely depends on early diagnosis and treatment and thus imaging plays a crucial role. It can not only diagnose an emphysematous infection, but also reveal the extent of the disease as far as other organs are concerned.
On our patient after four days of intravenous antibiotic administration, no clinical improvement was shown and the patient's clinical condition was worsening. Therefore, cholecystectomy was performed that revealed gangrenous cholecystitis and the patient remained on intravenous antibiotic administration for 5 more days. The cause of the infection was proven to be Escherichia coli. Her post-operative course was unremarkable and the patient was discharged after 7 days.
Emphysematous cholecystitis and cystitis are rather rare clinical conditions that can sometimes be seen together in diabetic patients [2, 3]. As a case of concurrent emphysematous cholecystitis, pyelonephritis and cystitis has never been reported before (to the knowledge of the authors) - this is the first in medical literature.

Differential Diagnosis List

Final Diagnosis

Concurrent emphysematous cholecystitis, pyelonephritis and cystitis

URL:	https://www.eurorad.org/case/15580
DOI:	10.1594/EURORAD/CASE.15580
ISSN:	1563-4086