Emphysematous cystitis

Clinical History

A 34-year-old woman presented with clinical symptoms of sepsis. Two years earlier, she underwent a mastectomy for breast cancer and she received adjuvant chemotherapy with Herceptin. One year later, multiple brain metastases were detected, for which she got pancranial radiotherapy in a palliative care setting. An abdominal CT examination was performed.

Imaging Findings

The CT examination showed the presence of air bubbles inside the bladder wall, preperitoneal and intraperitoneal. This suggested an emphysematous cystitis. No air was detected in the ureteral or pyelum wall.
Laboratory data showed white blood cell count of 16, 5 x 10*9/L with 94% neutrophils, an elevated sedimentation rate of 99 mm/h, LDH of 402 U/L and a fasting glucose of 221 mg/dl.
Microscopic examination of the urine revealed WBC count of 185/µl, RBC count of > 20/field and the presence of Enterobacter aerogenes (2+). Ten days later, Candida albicans (2+) was found in the urine.
Treatment with intravenous Augmentin and Flagyl was started. She was also catheterised for urinary drainage.
One week later, a new CT examination was performed and showed a significant decrease of the gas collections.

Discussion

Emphysematous cystitis is a rare condition, characterised by gas collections in the bladder wall.
The gas collections are carbon dioxide produced by the fermentation of glucose or protein by micro-organisms infecting the bladder. This gas collects in the bladder wall or lumen or even around the bladder (intraperitoneal) [1].
It is most commonly caused by E. Coli and other Enterobacter species. Other causative organisms include Proteus mirabilis, Staphylococcus aureus, Streptococcus, Klebsiella pneumoniae, Nocardia, Clostridium perfringens and Candida albicans [1, 4]
More than 50% of the patients are diabetic. Other causes are neurogenic bladder, bladder outlet obstruction, urinary catheters, end-stage renal disease, chronic urinary tract infections and immunosuppression. There is a 2:1 female to male predominance [3].
The present case indicated three of these factors: female patient, decrease in the immune resistance of the patient due to the palliative stage of her metastatic breast cancer and diabetes mellitus.
Emphysematous cystitis can be an incidental finding on imaging or can cause dysuria, haematuria, pneumaturia, fever, abdominal pain and even life-threatening sepsis [1, 3, 4].
It can be diagnosed radiologically with simple plain film of the abdomen, CT or US. Radiography shows a curvilinear radiolucency in the bladder wall. CT is more sensitive and can more accurately define the extent and severity of the disease. It can detect ascending cases of emphysematous cystitis (emphysematous pyelonephritis for example), which have higher mortality rates and need more aggressive (sometimes surgical) treatment [4].
Treatment usually consists of intravenous antibiotics therapy, bladder drainage and glycaemic control with correction of underlying disorders (if possible) [4].
Other possible causes for the presence of air in the bladder lumen, including vesicocolic or vesicovaginal fistula, must be excluded.

Differential Diagnosis List

Final Diagnosis

Emphysematous cystitis

URL:	https://www.eurorad.org/case/9531
DOI:	10.1594/EURORAD/CASE.9531
ISSN:	1563-4086