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A patient with urgency, frequency, and low serum C reactive protein concentration

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Q1: What do the computed tomogram and abdominal erect film show?

The pelvic computed tomogram (CT) showed typical intramural and intraluminal air bubbles accumulation in the urinary bladder (fig 1). Abdominal erect film taken right after the computed tomogram also showed a clear picture of curvilinear gas along the bladder wall (fig 2).

Q2: What is the diagnosis?

Emphysematous cystitis, glycosaemia, and hypokalaemia were proposed.

Q3: What is the appropriate treatment for this patient?

The treatment of emphysematous cystitis is by controlling glycosuria, glycosaemia, and systemic antibiotics. Drainage of urine is also suggested. If these treatments are not successful, surgical debridement is required.

Prognosis

The patient had hypokalaemia and was treated immediately. At the same time, she was treated with urinary drainage, antibiotics, and blood sugar control. However, she was admitted to the intensive care unit because of respiratory failure, septic shock, and an episode of seizure attack. Urinary culture showed Escherichia coli infection. After 25 days in the intensive care unit and antiepileptic drug treatment, her condition became stable and she was transferred to a ward. She was discharged 40 days after admission.

Discussion

Emphysematous cystitis is a rare complication of urinary tract infection.1 Most of the patients with this disease are diabetic, with a higher incidence in women.2 Definite diagnosis is based on computed tomography, ultrasonogram, or urography. E coli is the most commonly isolated bacteria.1 Treatment of this rare complication is by controlling diabetes mellitus, systemic antibiotics, and adequate drainage of urine.3 Surgical debridement or cystectomy also had been reported.4 Even more important is an awareness of this life threatening disease that can be diagnosed in the emergency department.

Increased plasma concentrations of C reactive protein have been reported to be sensitive indicators of infection in adults with diabetic ketoacidosis.5 It also can be used as screening tests to distinguish pyonephrosis and infected hydronephrosis from simple, uncomplicated hydronephrosis.6 However, increased serum concentrations of C reactive protein have been found regularly in girls with acute clinical pyelonephritis but only infrequently, about 5%, in those with clinical cystitis.7 No specific discussion about emphysematous cystitis and serum C reactive concentration can be found in the literature.

Despite the strong image evidence of the computed tomogram and clinical symptoms, the woman in this case report had a low serum C reactive protein concentration at the time of emphysematous cystitis was diagnosed. This rare case highlights that a patient of dysuria and low abdominal discomfort with low C reactive protein concentration is still at risk of severe urinary tract infection and needs prompt treatment. The treatment regimens are dictated by the clinical presentation of the patient and not a reliance on single test results.

Final diagnosis

Emphysematous cystitis induced septic shock.

References

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