Unusual Cystitis

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     A 68-year-old woman with diabetes mellitus that was treated with insulin was hospitalized because of abdominal pain and vomiting. She had been treated empirically for a urinary tract infection with trimethoprim–sulfamethoxazole for five days before admission. Her temperature was 38.4°C. Her abdomen was soft, with marked tenderness in the suprapubic area. Her leukocyte count was 45,000 per cubic millimeter, with 92 percent segmented neutrophils and 5 percent band forms. The glucose level was 569 mg per deciliter (31.6 mmol per liter), the blood urea nitrogen level was 57 mg per deciliter (20.3 mmol per liter), and the creatinine level was 2.8 mg per deciliter (247.5 μmol per liter). Urinalysis showed a pH of 7.5 with the presence of blood and 8 to 10 white cells per high-power field. A computed tomographic (CT) scan of the abdomen and pelvis showed distention of the urinary bladder in excess of 20 cm in the craniocaudal dimension because of the presence of intramural gas (arrow). A urine culture grew Proteus mirabilis. A 20-French Foley catheter was inserted. The patient was treated with gentamicin followed by piperacillin–tazobactam and then by amoxicillin–clavulanate. A follow-up CT scan, obtained six days later, showed complete resolution of the emphysema. The patient's blood urea nitrogen and creatinine levels returned to normal.

    Emphysematous cystitis is a rare disorder characterized by the collection of gas in the bladder wall and lumen. It results from infection of the bladder by gas-forming organisms. Predisposing factors include diabetes mellitus, neurogenic bladder, bladder-outlet obstruction, and recurrent urinary tract infection.

    Keyvan Ravakhah, M.D., M.B.A.

    Ramona Simionescu, M.D.

    Huron Hospital, Cleveland Clinic Health System

    Cleveland, OH 44112

    http://www.100md.com/html/DirDu/2006/11/29/30/59/00.htm