Emphysematous cystitis following a transrectal needle guided biopsy of the prostate

  • Takeshi Hashimoto1,

    Affiliated with

    • Kazunori Namiki1Email author,

      Affiliated with

      • Ayako Tanaka1,

        Affiliated with

        • Kenji Shimodaira1,

          Affiliated with

          • Tatsuo Gondo1 and

            Affiliated with

            • Masaaki Tachibana1

              Affiliated with

              BMC Infectious Diseases201212:322

              DOI: 10.1186/1471-2334-12-322

              Received: 17 January 2012

              Accepted: 12 November 2012

              Published: 26 November 2012

              Abstract

              Background

              Emphysematous cystitis (EC) is a comparatively rare urinary tract infection characterized by air within the bladder wall and lumen and is usually associated with immunosuppression or poorly controlled diabetes mellitus.

              Case presentation

              We report a case of EC in a 70-year-old man who recently underwent transrectal ultrasound needle-guided prostate biopsy, after which he underwent pylorogastrectomy. He did not have any history of diabetes mellitus or any immunosuppressive disease. The patient developed severe sepsis, requiring intravenous antibiotics and urinary catheterization. Despite therapy, the patient developed disseminated intravascular coagulopathy and acute respiratory distress syndrome. Therefore, he was admitted to the intensive care unit, antibiotic coverage was broadened, and danaparoid sodium and sivelestat sodium hydrate was administered. After 20 days, the patient’s condition improved, and on the 28th day, the patient was discharged to home in a good condition without any sequelae.

              Conclusion

              Prompt diagnosis and treatment are warranted to prevent potential morbidity of and mortality in cases of EC.

              Background

              Emphysematous cystitis (EC) is the presence of intramural gas along with or without luminal gas within the bladder caused by primary infection of the lower urinary tract in a gas-producing organism. The disease is most common among middle-aged diabetic women and is relatively rare in patients who do not have immunosuppressive disease.

              Case presentation

              A 70-year-old man, who did not have any history of diabetes mellitus, long-term steroid use, abnormalities in the immune system, or long-term urinary catheter use and a normal digital rectal examination result, had elevated serum prostatic specific antigen (PSA) level of 13.3 ng/mL. Because of the elevated serum PSA level and stomach cancer, the patient underwent a transrectal ultrasound needle-guided prostate biopsy and a pylorogastrectomy on the same day. Before the procedures, the patient received a rectal enema and an oral fluoroquinolone antibiotic.

              The transrectal ultrasonography indicated a gland weighing 60 g without any abnormalities. The patient underwent an uneventful 12-core prostate biopsy. However, after 4 days, the patient developed a fever (body temperature, 101°F) associated with gross hematuria. The patient was noted to have a white blood cell count of 10500 cells/mm3, a hemoglobin level of 9.7 g/dL, a platelet count of 17.8 × 104/mm3, and a C-reactive protein level of 14.8 mg/dL. The urinalysis result demonstrated more than 50 white blood cells/h.p.f. Urine and blood culture specimens were obtained. On a bladder scan, a post-void residual urine volume of 350 mL was noted. Acute prostatitis was diagnosed, and intravenous meropenem therapy was initiated. Despite the administration of the antibiotic, the patient’s body temperature was still 104°F. Subsequently, a plain radiograph of the abdomen and a computed tomography (CT) image of the abdomen and pelvis (with and without intravenous contrast) were obtained. The plain radiograph of the abdomen revealed a nonspecific gas pattern and a small amount of air in the true pelvis in the shape of the bladder (Figure  1).
              http://static-content.springer.com/image/art%3A10.1186%2F1471-2334-12-322/MediaObjects/12879_2012_2102_Fig1_HTML.jpg
              Figure 1

              Plain radiograph of the abdomen showing a nonspecific gas pattern and a small amount of air in the true pelvis, in the shape of the bladder.

              The diagnosis of EC was confirmed on the CT image, which revealed the presence of extensive gas within the wall of the urinary bladder (Figure  2).
              http://static-content.springer.com/image/art%3A10.1186%2F1471-2334-12-322/MediaObjects/12879_2012_2102_Fig2_HTML.jpg
              Figure 2

              Computed tomography image showing extensive gas within the wall of the urinary bladder.

              The blood and urine cultures were positive for pan-sensitive Escherichia coli. A urinary catheter was then inserted for draining the bladder. Despite these maneuvers, the patient developed disseminated intravascular coagulopathy (DIC) and acute respiratory distress syndrome, requiring transfer and monitoring in the intensive care unit. The patient’s antibiotic treatment was changed from ciprofloxacin to vancomycin. In addition to the standard supportive procedures, patient therapeutic regimen of danaparoid sodium and sivelestat sodium hydrate was initiated. After 20 days of conservative management, the patient’s condition improved, and on hospital day 28, the patient was discharged to home in a stable condition. After 1 year, the patient did not report any sequelae from the EC.

              Discussion

              EC is a relatively uncommon condition. Of the cases of EC, 60% are associated with diabetes mellitus [1, 2]. Kelesidis et al. [3] reported that EC was commonly observed in patients who had either diabetes or other immunosuppressive diseases. Moreover, they reported that the other risk factors were old age, female sex, urinary tract outlet obstruction, structural abnormalities of the bladder, chronic urinary tract infection, hemorrhagic cystitis, and alcoholic disease.

              In the present case, EC developed secondarily after major surgery and prostate biopsy. Kimura et al. [4] reported that surgical and traumatic injuries profoundly affect innate and adaptive immune responses and that a significant suppression in cell-mediated immunity after an excessive inflammatory response appears to be responsible for the increased susceptibility to subsequent sepsis. This report might indicate that the immune system of the patient weakens with surgery, in a similar manner observed in immunosuppressive disease. In our recent review of the literature, some of the reported cases of EC developed secondarily from medical intervention (Table  1).
              Table 1

              Emphysematous cystitis occurred secondary to medical intervention

              Author

              Year

              Age

              Gender

              Diabetes mellitus

              Medical interference

              Complication

              Treatment (except antibiotics)

              Culture

              Prognosis

              Kalra O.P.

              1993

              35

              M

              -

              renal transplant

              chronic glomerulonephritis

              graft nephrectomy

              Klebsiella pneumoniae

              died

              Dimitris D.

              1996

              59

              M

              +

              orchiectomy

              epididymitis

              surgical debridement cystotomy

              E. coli

              recovered

              Anwar N.

              2002

              57

              F

              +

              peritoneal dialysis

              hypertension, chronic kidney disease

               

              E. coli

              recovered

              Van G. E.

              2004

              50

              F

              No data

              hysterectomy

              vesicovaginal fistula

              intensive care, urinary diversion

              Klebsiella pneumoniae enterococcus faecalis

              died

              Thomas A.

              2006

              80

              M

              -

              colectomy

              colitis

              urinary drainage

              E. coli

              recovered

              Yokoo T.

              2007

              68

              F

              +

              hemodialysis

              hypertension, chronic kidney disease

               

              E. coli

              recovered

              Carla M.

              2008

              81

              M

              -

              replace the mitral valve

              myocardial infraction

              intensive care

              Enterobacter aerogenes

              died

              Mok H.P.

              2010

              80

              F

              No data

              anterior resection of rectum

              data not reported

               

              E. coli

              recovered

              Sereno M.

              2010

              70

              F

              +

              chemotherapy

              breast cancer

               

              E. coli

              recovered

              Lang E.K.

              2011

              44

              M

              No data

              renal transplant

              hypertension, chronic kidney disease

              surgical debridement, nephrostomy

              No data

              not reported

              present case

              2012

              70

              M

              -

              gastrectomy, prostate biopsy

              benign prostatic hypertrophy

              urinary drainage

              E. coli

              recovered

              E.coli: Escherichia coli.

              Patients with EC might have varied clinical presentations, ranging from incidental diagnosis on abdominal imaging to severe sepsis [5]. Symptoms and signs include stomach pain, irritative voiding symptoms, hematuria, and pyuria. Pneumaturia is also a characteristic symptom of EC but requires differentiation from vesicoenteric fistula and vesicovaginal fistula [1, 2, 6, 7]. EC was first reported in a canine in 1926. The occurrence of EC in a human was first reported in 1961 [1]. Improved imaging techniques over the past several decades have allowed increased detection of EC. Plain radiography of the abdomen has a sensitivity of 95% in detecting air within the bladder wall. However, CT is needed to obtain a differential diagnosis of EC and to rule out vesicoenteric fistula or vesicovaginal fistula. It is feasible that magnetic resonance imaging and ultrasonography may prove to be valuable diagnostic tools for EC [7, 8].

              The mechanism of aerosis in EC is still unknown. The bacterium responsible for approximately 58–60% of the reported EC cases is E. coli, followed by Klebsiella pneumoniae, accounting for approximately 18–21% of the cases [1, 6, 7]. The other bacteria found to be associated with EC include Proteus, Staphylococcus, and Clostridium. It is thought that these organisms can ferment glucose present in urine, producing acid and CO2. The transportation of accumulated CO2 away from the tissue is disrupted by local inflammation or obstructive uropathy. The accumulation of gas further increases the local pressure and may lead to infarction of the adjacent tissues, augmenting the barrier to gas transportation and thus creating a vicious cycle [6].

              Treatment of EC consists of broad-spectrum antibiotics and placement of a urinary catheter to drain the bladder. In our case, we hesitated to insert the urethral catheter because acute prostatitis is believed to lead to EC and insertion of a urethral catheter was generally not preferred for acute prostatitis. Furthermore, we were also uncertain whether a cystostomy should be performed, as it might not be suitable in cases with an infectious bladder. With ingravescent course, the patient needed to undergo urine drainage because of residual urine. We, then, decided to insert a urethral catheter because he rejected cystostomy. If a patient has diabetes mellitus, then immediate blood glucose control should be warranted. In severe cases, septicemia may lead to DIC, which occurred in our patient. The death rate from EC is reported to be approximately 7–10%, illustrating the need for rapid diagnosis and early treatment [1, 6, 9].

              Conclusions

              We report a case of EC occurring after a transrectal needle-guided biopsy of the prostate. The patient did not have any history of diabetes mellitus and urinary tract infection. However, in addition to the transrectal biopsy, stress by pylorogastrectomy was thought to cause the adverse event. Successful management of EC depends on its early diagnosis, with correction of the underlying causes and administration of the appropriate antibiotics. Early detection and prompt treatment are encouraged.

              Consent

              Written informed consent for publication of this case report and any accompanying images was obtained from the parents. A copy of the written consent is available for review by the editor-in-chief of this Journal.

              Abbreviations

              DIC: 

              Disseminated intravascular coagulopathy

              EC: 

              Emphysematous cystitis

              CT: 

              Computed tomography

              PSA: 

              Prostatic specific antigen.

              Declarations

              Authors’ Affiliations

              (1)
              Department of Urology, Tokyo Medical University

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              10. Pre-publication history

                1. The pre-publication history for this paper can be accessed here:http://​www.​biomedcentral.​com/​1471-2334/​12/​322/​prepub

              Copyright

              © Hashimoto et al.; licensee BioMed Central Ltd. 2012

              This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://​creativecommons.​org/​licenses/​by/​2.​0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.