Asploro Journal of Biomedical and Clinical Case Reports
ISSN: 2582-0370
Article Type: Case Report
DOI: 10.36502/2024/ASJBCCR.6364
Asp Biomed Clin Case Rep. 2024 Aug 09;7(3):205-209

An Unusual Case Presentation of Coexistence of Emphysematous Cystitis and Bilateral Emphysematous Pyelonephritis: A Case Report

Xu Hu¹, Yujie Diao¹, Yiqin Xia^1iD*
1Department of Emergency Medicine, West China Hospital, West China School of Medicine, Sichuan University, Chengdu, China

Corresponding Author: Yiqin Xia ^{ORCID iD}
Address: Department of Emergency Medicine, West China Hospital, Sichuan University, 37 Guoxue Road, Chengdu 610041, Sichuan, China.
Received date: 14 July 2024; Accepted date: 02 August 2024; Published date: 09 August 2024

Citation: Hu X, Diao Y, Xia Y. An Unusual Case Presentation of Coexistence of Emphysematous Cystitis and Bilateral Emphysematous Pyelonephritis: A Case Report. Asp Biomed Clin Case Rep. 2024 Aug 09;7(3):205-209.

Copyright © 2024 Hu X, Diao Y, Xia Y. This is an open-access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium provided the original work is properly cited.

Keywords: Emphysematous Cystitis, Emphysematous Pyelonephritis, Type 2 Diabetes

Abstract

Background: Emphysematous cystitis (EC) and emphysematous pyelonephritis (EPN) are severe emphysematous urinary tract infections with high mortality. Early diagnosis is often missed due to the lack of typical clinical manifestations.
Case Presentation: A 64-year-old woman with type 2 diabetes was transferred to the emergency department for cough and expectoration with shortness of breath. A CT scan revealed gas formation in the bilateral renal pelvis, bilateral ureter, and bladder cavity. Urine bacterial cultures showed Escherichia coli and Streptococcus gallolyticus. The patient’s bladder was drained, and she was administered antibiotics, insulin, and a non-invasive ventilator. The gas disappeared completely, and the patient recovered uneventfully.
Conclusion: This is the first reported case of Escherichia coli combined with Streptococcus gallolyticus infection in EC and EPN. More attention should be paid to EC and EPN in diabetes patients. Early conservative treatment is effective.

Introduction

Emphysematous cystitis (EC) and emphysematous pyelonephritis (EPN) are severe emphysematous urinary tract infections (EUTI), often caused by retrograde infection of Gram-negative bacteria. The main feature of these diseases is the formation and accumulation of gas in the bladder wall and cavity, renal collecting system, renal parenchyma, and around the kidney [1]. The most common pathogen is Escherichia coli, accounting for about 70% of cases, followed by Klebsiella pneumoniae, Proteus mirabilis, and Pseudomonas aeruginosa [2,3]. Diabetes is the most common risk factor; other factors include old age, female sex, immunosuppression, recurrent urinary tract infections, neurogenic bladder, indwelling catheters, urinary tract obstruction, alcohol use, and immunocompromised states [4-8]. The fatality rate of emphysematous pyelonephritis is about 11% to 42%; type I emphysematous pyelonephritis and bilateral emphysematous pyelonephritis are important risk factors for death in patients with emphysematous pyelonephritis [9]. We report a case of a patient with type 2 diabetes with emphysematous cystitis and emphysematous pyelonephritis who had urine cultures positive for Escherichia coli and Streptococcus gallolyticus.

Case Presentation

A 64-year-old woman with type 2 diabetes for 10 years was transferred to our emergency department for a cough and expectoration with shortness of breath after exercise for 10 days, worsening over the past 5 days. She did not have fever, abdominal pain, backache, or urinary tract irritation. Physical examination revealed a temperature of 36.6°C, a respiratory rate of 34 breaths/min, blood pressure of 149/76 mmHg, and peripheral oxygen saturation of 74%. Auscultation of the lungs revealed wet rales, and there was tenderness in the upper abdomen and left lower abdomen.

Laboratory analysis results showed: hemoglobin 83 g/L (reference range 115150 g/L), white blood cell count 13.15×10⁹/L (3.5 ~ 9.5×10⁹/L), percentage of neutrophilic granulocytes 76.1% (40 ~ 75%), glucose 11.81 mmol/L (3.9 ~ 5.9 mmol/L), urea nitrogen 10.4 mmol/L (3.1 ~ 8.8 mmol/L), creatinine 211 μmol/L (49 ~ 88 μmol/L), albumin 32 g/L (40 ~ 55 g/L), B-type natriuretic peptide precursor 2439 ng/L (<334 ng/L). Urine sediment microscopy showed white blood cells 59/HP (05/HP), urine protein qualitative 2+ (negative), procalcitonin 0.77 ng/ml (<0.046 ng/ml), and C-reactive protein 11.1 mg/L (<5 mg/L). Urine bacterial cultures showed Escherichia coli and Streptococcus gallolyticus.

Abdominal CT scan showed bilateral renal pelvis and bilateral ureter gas accumulation (Fig-1A), bladder cavity gas accumulation (Fig-1B), right kidney atrophy, right ureter and bilateral renal pelvis effusion, and bilateral renal pelvis and ureter wall thickening. Chest CT scan showed scattered ground-glass opacities, patches, and streaks in both lungs.

Fig-1: Abdominal CT taken on admission

We diagnosed emphysematous cystitis, emphysematous pyelonephritis, chronic renal insufficiency, type 2 diabetes, pulmonary infection, and type I respiratory failure. The patient’s bladder was drained, and empiric treatment with piperacillin-tazobactam was initiated for 5 days. On the 4^th day after admission, procalcitonin increased from 0.77 ng/ml to 3.85 ng/ml. Antibiotics were escalated to meropenem for 3 weeks based on procalcitonin and urine culture results (urine culture results and drug sensitivity results shown in Table-1 and Table-2), and finally de-escalated to cefmetazole for 13 days (Fig-2). Insulin was used to control blood sugar, and a non-invasive ventilator assisted in treating acute respiratory failure for 2 weeks. CT imaging of the abdomen revealed that gas in the bilateral renal pelvis, bilateral ureter, and bladder cavity had been completely absorbed 2 weeks later (Fig-2A and Fig-2B). The patient was discharged after 38 days of treatment.

Fig-2: Abdominal CT taken 2 weeks after admission

Table-1: Urine Culture Result 1: Streptococcus Gallolyticus

Table-2: Urine Culture Result 2: Escherichia coli

Discussion

EPN is a necrotizing infection of the renal parenchyma, but reports of bilateral EPN with EC are rare. This case involves an elderly woman with type 2 diabetes who was not receiving regular diabetes treatment. The main pathogenic factors are poor control of blood sugar levels and glucose in kidney tissue and the urinary tract being lysed by gas-producing bacteria, producing a large amount of carbon dioxide, hydrogen, ammonia, etc. Additionally, the patient’s urine culture was suggestive of Escherichia coli, which, consistent with most literature reports, induces anaerobic metabolism after infection, resulting in gas formation in the bladder, kidneys, and surrounding tissues. Streptococcus gallolyticus was also isolated from the urine culture of this patient, which belongs to the Streptococcus bovis/Streptococcus equi complex. This bacterium is an opportunistic pathogen that usually colonizes the human intestinal and urinary tracts. A retrospective study in Italy reported that among 63.6% of patients with UTI caused by SGSP, diabetes was the most common underlying disease (31.8%) [10]. This is the first reported case of Escherichia coli combined with Streptococcus gallolyticus infection in EC and EPN.

Abdominal CT examination is the main method for diagnosing the disease. According to the radiological findings on computed tomography scans, EPN is classified into four classes [11]:

Class 1: Gas in the collecting system only
Class 2: Gas in the renal parenchyma without extension to the extrarenal space
Class 3A: Extension of gas or abscess to the perinephric space
Class 3B: Extension of gas or abscess to the pararenal space
Class 4: Bilateral EPN or solitary kidney with EPN

According to the course of the disease, it is mainly divided into two types [12]. Type I is acute fulminant type, characterized by renal parenchymal destruction, intravascular thrombosis, microabscesses, and gas formation, with a mortality rate as high as 69%. Type II is subacute progressive type, characterized by liquid accumulation with gaseous separation in the kidney and perirenal tissue, with a mortality rate of about 18%. Based on the above classification, our patient was allocated to Type I and Class 4, respectively. Percutaneous catheter drainage (PCD) or ureteral catheter combined with antibiotics is the main treatment for patients with Type II or Class 1 and Class 2, and nephrectomy is often required for patients with Type I or Class 3 and 4 who fail to respond to PCD combined with antibiotics.

Conclusion

In summary, due to the typical imaging evidence and potential mortality of EC and EPN, prompt intervention and management are required even in the absence of symptoms. Aggressive drainage and antibiotic management are the main interventions, with surgical intervention only if necessary. We also found that asymptomatic EPN and EC may have a good prognosis.

Consent for Publication

Written informed consent was obtained from the patient’s next-of-kin for the publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.

Ethics Approval and Consent to Participate

This study was approved by the Ethics Committee of West China Hospital of Sichuan University. Written informed consent was obtained from the individual and her husband for the publication of any potentially identifiable images or data included in this article.

Data Availability Statement

The original contributions generated for the study are included in the article; further inquiries can be directed to the corresponding authors.

Author Contributions

Xu Hu wrote most of the manuscript and aided in the final editing of the text. YuJie Diao retrieved most of the information relevant to the case presentation. Yiqin Xia was in charge of our patient and critically reviewed the final manuscript. All the authors read and approved the final manuscript.

Conflict of Interest

The authors have read and approved the final version of the manuscript. The authors have no conflicts of interest to declare.

Funding

There was no funding received for this paper.

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