BJID 2008; 12 (December)
Received on 20 June 2008; revised 13 November 2008.
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The Brazilian Journal of Infectious Diseases 2008;12(6):552-554.
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Emphysematous Cystitis – A Case Report
Carla Meira, Ana Jerónimo, Carlos Oliveira, Augusta Amaro and Cristina Granja
Intensive Care Department, Pedro Hispano Hospital; Matosinhos, Portugal
Emphysematous Cystitis is a primary infection of the bladder with production of gas by bacteria. The infection is
uncommon, still has obvious clinical importance due to its morbidity and mortality potential, as the following case
enlightens. We report a clinical case of a patient admitted with acute myocardial infarction who developed an acute
emphysematous cystitis, a further complication in his long and complex period of hospitalization.
Key-Words: Emphysematous cystitis, urinary tract infections.
Emphysematous Cystitis is a primary infection of the
bladder with production of gas by bacteria. It is usually
diagnosed in diabetic patients with poor glycemic control or
in immunocompromised. The severity of the clinical picture
varies from simple cystitis-like symptoms to full-blown sepsis.
Therefore, a high index of clinical suspicion is essential in an
early phase. The appropriate antibiotic therapy is usually
curative, but in more complex cases surgery may be required
. The infection is uncommon, still has obvious clinical
importance due to its morbidity and mortality potential, as the
following case enlightens. We report a clinical case of a patient
admitted with acute myocardial infarction who developed an
acute emphysematous cystitis, a further complication in his
long and complex period of hospitalization.
A 81-year-old caucasian male with cardiovascular
hypertension and dyslipemia was admitted to the emergency
ward with non ST-segment elevation acute myocardial
infarction. After acute phase treatment, a coronarography
showed two vessels disease and he underwent an angioplasty
of the right coronary with implantation of a Cypher stent. The
patient had a good recovery in the initial stage, but its condition
worsened during the hospitalization and he developed acute
lung edema. The echocardiography showed serious mitral
insufficiency resulting from rupture of the papillary muscle. A
cardiac operation was performed in order to replace the mitral
valve for a biologic prothesis and implantation of venous
bypass graft to the anterior descending coronary artery. The
operation went without incidents. The patient continued with
oral anticoagulants and the remaining medication. Urinary
catheterization was performed during the postoperative
Seven days after surgery his condition worsened again
with deterioration in the general state and prostration in
association with the appearance of haematuria. On physical
examination he presented dehydrated, pale, sweaty, tachypneic
with O2 Saturation: 84% (FiO2: 0.6), signs of poor peripheral
perfusion. Vital signs: temperature: 37º centigrade, blood
pressure: 80/40 mm Hg, heart rate: 80 bpm. Cardiopulmonary
auscultation showed tachycardia, no other abnormalities.
Abdomen was soft and depressible, no pain on palpation.
Biochemical analysis showed increase in inflammatory markers
and acute renal failure: Haemoglobin: 14 g/dL; Leukocyte: 25
x10³ µ/L; Neutrophils: 91%; Platelet: 188x10³ µ/L; Urea/
Creatinine: 161/4 mg/dL; Na+ 132 mEq/L, K+ 5.9 mEq/L, C-
Reactive Protein: 29 mg/dL; Coagulation study was abnormal:
aPTT: 51; INR: 5.9; Blood gas analysis was as follow: pH 7.51;
PCO2 15 mmHg; PO2 115 mmHg; HCO3 12 mmol/L; Lactates:
6.6 mmol/L. A nosocomial urinary tract infection with severe
sepsis was assumed as the diagnosis. Microbiological
products were collected and the patient was empirically treated
with piperacillin/tazobactam. Abnormal coagulation was
corrected with vitamin K. Echocardiogram was repeated to
exclude cardiac complications: valvular prothesis in mitral
position had normal function, systolic function of the left
ventriculus was preserved and no other relevant changes were
detected. Initial aggressive treatment with fluids and antibiotic
was not successful and the patient developed septic shock
being admitted to the intensive care unit with multiorganic
dysfunction. Haematuria was increasing and abdominal pain
was now present. He was started on mechanical ventilation
and resuscitation with volume and amines. An abdominal scan
revealed gas in the excretory urinary tracts and bladder. A
further explanation for the images was necessary and a CT-
scan was performed. Multiple gas pockets along the vesical
wall were present, and the images were compatible with the
diagnosis of emphysematous cystitis (Figure 1). Enterobacter
aerogenes was isolated in urine culture and hemoculture.
Subsequently antibiotic therapy was substituted for
Ciprofloxacin, in accordance with antibiogram.
The clinical evolution was unfavourable during the first
days in the intensive care unit, but it slowly and gradually
improved. The patient was ready for ventilator weaning and
extubation on the second week. Hemodynamic support with
amines was stopped. The urine culture was taken once again
and presented sterile. When clinically stable, he was
transferred to the intermediate care unit, where his condition
continued slowly improving. After 10 days a new worsening
of his clinical condition was present, with persistent fever
and respiratory complaints, compatible with a nosocomial
BJID 2008; 12 (December)
respiratory infection. New courses of empirical large spectrum
antibiotics were started, with no clinical improvement.
Microbiologic results were negative. After discussion of the
poor prognosis with the patient’s family, it was clear that there
was no benefit in proceeding with invasive resuscitation
manoeuvres and the patient died a few days after.
Despite belonging to a low percentage of all the urinary
tract infections, gas-producing infections are relevant as they
may lead to death. Three categories of this type of infections
are recognized: emphymatous pyelonephritis, emphymatous
pyelitis or emphymatous cystitis.
Emphymatous pyelonephritis is a necrotic infection. The
gas is produced in the renal and perirenal parenchyma and
90% of the cases are reported in diabetic patients. The delay
on the appropriate therapy contributes to a high mortality
rate, in some case series up to 80% .
Emphymatous cystitis is a rare disease that is mainly
diagnosed in diabetic and immunocompromised patients. It is
also reported to be in association with neurogenic bladder,
obstruction of the urinary tracts, catheter use and chronic
infections of the urinary tract.
The microorganisms most often involved in this infection
are Escherichia coli and Klebsiella pneumonia and the less
common are Enterobacter, Proteus, Streptococci and Candida
. Despite being the bacteria the most common agent, the
funguses may also be responsible for this clinical picture .
The exact mechanism by which the gas is produced in
the emphymatous infection is not quite clear. In diabetic
patients, one of the reasons seams to be the production of
CO2 by the microorganisms through the fermentation of
glucose, which occurs when the glucose concentration is
high. Since the emphymatous infections may occur in
nondiabetic patients, it has been suggested that the urinary
lactulose and tissue proteins may be useful as substrate to
the gas production. Another factor that may help in this
process is the impaired transportation of gas due to the local
inflammation or some kind of obstructive process increasing
the local pression and decreasing the circulation. This may
involve tissue necrosis which becomes a good culture for
pathogens to produce gas .
The most common clinical features are fever and abdominal
pain along with dysuria, haematuria and pneumaturia.
The diagnosis is provided by radiographic image. The
most obvious radiographic clues are small pockets of gas in
the mucous membrane of the bladder.
Other causes for the presence of air in the bladder such as
fistula with the intestine or vagina, after trauma or
instrumentation, have to be excluded .
The appropriate treatment involves endovenous antibiotic
theraphy with broad-spectrum such as fluoroquinolones,
penicillin with inhibitor of the beta-lactamases (imipenem,
ticarcilin/clavulanat) or third-generation cefalosporines.
Antifungal agents may be used (systemic or intravesical), if a
fungus infection is reported . The full recovery from any
infection with gas production depends on early diagnosis
plus correction of the subjacent causes, glycemic control,
long-term therapeutic with antibiotic therapy (3 to 6 weeks)
and surgery, if required .
The reported case shows the seriousness and the atypical
presentation that this infection may assume. The diagnosis
was made indeed on a non-diabetic patient in an unusual
clinical situation. The diabetes mellitus and the bad glycemic
control are the main risk factors for this type of infection. We
considered that the indwelling urinary catheter during the
hospitalization may have been the responsible factor for the
infection development. The agent isolated from this patient,
the Enterobacter aerogeneos, also is not reported as being
the most common. The empiric broad-spectrum antibiotic
(piperacilin/tazobactam) used for the nosocomial urinary tract
infection was found to be ineffective. The organism was
resistant according to the biogram and a therapeutic
adjustment was needed. This relatively rare pathology has a
high mortality and morbidity rate but despite the patient age
and previous complex clinical situation, the initial conservative
treatment and the support offered in the intensive care unit
enabled a favourable evolution. Subsequently, the patient
developed complications involving a nosocomial respiratory
infection without favourable outcome which was fatal.
Interesting to reflect that this patient survived an acute
myocardial infarction followed by a complex cardiac surgery
but nosocomial infections were the main factors affecting his
prognosis and survival. Our medical resources, especially
antibiotic therapies, are still not sufficiently effective against
this type of conditions. Control of risk factors and early clinical
Figure 1. CT scan of the pelvis revealing gas in the bladder
and the bladder wall.
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suspicion are important additional therapeutic measures to
prevent unfavourable complications.
Sónia Miranda for translating this article.
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