Clinical History
A 40-year-old female patient with a past medical history of uncontrolled diabetes mellitus, chronic pancreatitis, diverticulitis, a pelvic abscess, and a colovesical fistula was admitted to the hospital with a chief complaint of abdominal pain, prompting an abdomino-pelvic CT.
Imaging Findings
A 40-year-old female patient with a past medical history of uncontrolled diabetes mellitus, chronic pancreatitis, diverticulitis, a pelvic abscess, and a colovesical fistula was admitted to the hospital with a chief complaint of abdominal pain, prompting an axial abdomino-pelvic CT with oral and IV contrast. CT was performed showing both kidneys symmetric in appearance with bilateral striated nephogram with perinephric fat stranding (Figs. 1, 2, 3, 5). This finding was most concerning for acute pyelonephritis. An air fluid-level was present in the urinary bladder which was distended with pockets of air throughout the bladder wall most concerning for emphysematous cystitis (Fig. 4, 5). The patient was further evaluated for infectious disease and extended-spectrum beta-lactamase producing E. coli was grown confirming acute pyelonephritis with emphysematous cystitis.
An incidental finding of multiple calcifications was noted in the head and neck of the pancreas most compatible with chronic pancreatitis.
Discussion
Emphysematous cystitis is a rare urinary tract infection in which collections of gas pockets are formed within and around the bladder wall. These gas pockets are suspected to be formed by gas producing bacteria or fungi through fermentation with the most common causative organisms being Escherichia coli and Klebsiella species, although Enterobacter, Enterococcus, Clostridium perfringens, and Candida albicans among others have been identified as well [1]. Emphysematous cystitis is almost always associated with diabetes mellitus, as was the case with our patient (uncontrolled diabetes mellitus) [2]. Other common associations include elder age, gender: women, neurogenic bladder, recurrent urinary tract infections, bladder outlet obstruction, immunosupression, and indwelling urinary catheters. The most common chief complaint associated with emphysematous cystitis is severe abdominal pain although other typical urinary tract symptoms such as dysuria, fever, chills, nausea, haematuria, and/or increased urinary frequency may be present as well [2]. As clinical history and lab studies are typically similar to those found in patients with uncomplicated urinary tract infections, radiographic studies are the preferred diagnostic modality, particularly the CT examination which is more sensitive for picking up air in the bladder which may or may not be seen on a plain film [3]. Prompt diagnosis and treatment is imperative in order to prevent complications such as extension of the infection to the ureters and ultimately to the renal parenchyma, which seems to have happened in our patient. Bladder rupture and peritonitis are other possible complications [1]. After diagnosis, blood and urinary cultures should be obtained. In the meantime, the patient should be started on broad spectrum antibiotics and the blood glucose level should be controlled while awaiting the results. Bladder catheterization is indicated in majority of the patients while those with obstructive processes may require surgical intervention. Prognosis of emphysematous cystitis is good in those with early detection and treatment [3].
Differential Diagnosis List
1. Acute pyelonephritis with emphysematous cystitis2. Chronic pancreatitis
Renal infarction
Bladder carcinoma
Final Diagnosis
1. Acute pyelonephritis with emphysematous cystitis2. Chronic pancreatitis
