ObjectiveThis study aims to discuss and summarize the diagnosis and treatment of emphysematous pyelonephritis (EPN).MethodsRetrospective medical records review of all patients diagnosed with EPN from January 2017 to June 2023 in our hospital were analyzed. A total of eight patients (three males and five females) were enrolled. The mean age was 49.38 ± 3.48 years. Among them, one case was complicated by sepsis, two by emphysematous cystitis, two by chronic renal failure, four by diabetes, and five by urolithiasis. Upon admission, all patients received aggressive antimicrobial therapy. Surgical interventions consisted of drainage procedures tailored to each patient's specific condition along with management for upper urinary tract calculi present. Clinical data were analyzed in depth and compared with the previously published studies.ResultsAll patients complied with the protocol of catheter removal as scheduled and were discharged after complete recovery. No recurrence of infection was recorded during the follow-up.ConclusionsMost EPN patients suffer from severe and complex medical conditions. Selecting an appropriate surgical drainage strategy can significantly reduce the rates of infection recurrence, nephrectomy and mortality, thereby improving the patient's prognosis.

Emphysematous cystitis is an uncommon urinary tract infection characterized by the spontaneous formation of gas within the bladder and/or its wall. Computed tomography (CT) of the abdomen and pelvis is the imaging modality of choice. We present the case of a 78-year-old female admitted with abdominal pain and vomiting. Clinical examination revealed epigastric tenderness. Laboratory findings demonstrated an inflammatory syndrome and pyuria on urinalysis. An uncomplicated emphysematous cystitis, incidentally discovered, was diagnosed following an urgent CT scan of the abdomen and pelvis.

Emphysematous cystitis is a rare disease characterized by primary infection of the urinary bladder with gas-producing pathogens. We report the case of a patient admitted to the Ibnou Roch emergency department for 2 weeks of abrupt onset of low back pain, with an elevated infectious workup. Abdomino-pelvic CT revealed a typical case of emphysematous cystitis. The exact mechanism contributing to the formation of gas in such cases is unknown. Various theories have been suggested, including fermentation of glucose in urine, with emphasis on disequilibrium between gas formation and clearance. Emphysematous cystitis has a highly variable presentation and course, with a considerable potential for complications. Further diagnostic imaging is highly recommended in diabetic patients with urinary tract infection who present with abdominal pain and hematuria. Knowledge of this rare entity may lead to early diagnosis and appropriate management.

Emphysematous cystitis (EC) is a rare and potentially life-threatening infection of the bladder wall characterized by the presence of gas. It predominantly affects elderly females with diabetes mellitus. While the clinical presentation can vary, it commonly involves symptoms of urinary tract infection. This case report describes an unusual presentation of EC in a geriatric female complicated by culture-proven urosepsis. A 66-year-old female with a history of type 2 diabetes mellitus presented to the emergency department with fever, dyspnea, and tachypnea. She reported suprapubic pain, dysuria, and foul-smelling, murky urine for two days. Initial laboratory findings revealed leukocytosis, hyperglycemia, and elevated procalcitonin levels, indicating sepsis. Computed tomography (CT) of the abdomen and pelvis revealed air foci within the bladder wall, consistent with EC. Blood and urine cultures grew Escherichia coli resistant to multiple antibiotics but susceptible to amikacin and gentamicin. The patient was treated with intravenous amikacin and showed significant clinical improvement, with subsequent negative urine cultures. In conclusion, our study highlights a rare presentation of emphysematous cystitis complicated by culture-proven urosepsis in a geriatric female with multidrug-resistant Escherichia coli. Prompt diagnosis using CT imaging and appropriate antibiotic therapy based on culture sensitivities led to a successful outcome. This case underscores the importance of considering EC in elderly diabetic patients presenting with sepsis and urinary symptoms, even with atypical features.

Emphysematous Cystitis detected by point-of-care ultrasound

Emphysematous cystitis imaging insights: a case study of a non-diabetic patient

WCN25-3864 A Rare Case of Emphysematous Cystitis Linked to Early SGLT-2 Inhibitor Therapy in Diabetes

Emphysematous cystitis is a rare condition that can have fatal complications if left untreated. A timely diagnosis and proper treatment are crucial to achieving appropriate outcomes. Patients with this condition should be evaluated, and if necessary, conservative treatment or surgery should be provided. This case report describes a 73-year-old male patient with emphysematous cystitis who underwent conservative treatment for bladder rupture and reviews the existing literature on this topic. The gold standard for diagnosis of EC is a computerized tomographic scan. This condition should be evaluated, and if necessary, conservative treatment or surgery should be provided.

Background: Emphysematous pyelonephritis (EPN) is an uncommon, acute and severe necrotizing infection affecting the renal parenchyma, collecting system and surrounding tissues. This study was planned to describe the demographic, clinical, laboratory and imaging characteristics and in-hospital outcomes of patients with EPN. Methods: This retrospective study was done at BIRDEM General Hospital, Dhaka, Bangladesh between 2021 and 2023. Patients’ clinical, laboratory and imaging characteristics and in-hospital outcomes were recorded in case record forms at the time of discharge or death, if were any. Results: Total patients were 16 with female predominance (10, 62.5%). Mean age of patients was 57.1 (range 29 - 67) years. Risk factors for EPN were diabetes mellitus (16, 100%) and renal stones (3, 18.8%). Fever (16, 100%), loin pain (11, 68.8%), vomiting (10, 62.5%) and dysuria (10, 62.5%) were common presenting features. All (16, 100%) patients had leukocytosis and uncontrolled blood glucose (HbA1c >7%). Complications included acute kidney injury (AKI) (7, 43.8%), hyponatremia (5, 31.3%) and bacteremia (3, 18.8%). Escherichia coli (11, 68.8%) was the most common urinary isolate. Most patients (11, 68.8%) had class 2 EPN, 3 (18.8%) had class 3B and 1 (6.3%) had class 3A disease. One (6.3%) patient had class 4 EPN with emphysematous cystitis. Along with medical management, four (25%) patients required surgery (open drainage in 3, open drainage with double J stenting in 1). None required nephrectomy. Mean hospital stay was 8 (range 6 - 11) days and there was no death. Conclusion: EPN occurred predominantly among female diabetic patients with poor glycemic status, who presented with fever, loin pain, vomiting and dysuria. Two-fifths of patients had AKI and one-fourth required surgery. None required nephrectomy and there was no mortality. BIRDEM Med J 2025; 15(1): 5-8

Emphysematous cystitis is a rare form of urinary tract infection involving the presence of gas within the bladder. This condition occurs when gas-producing bacteria infect the bladder and generate gas bubbles inside it. The bacteria most commonly associated with emphysematous cystitis are those that produce gas as a result of glucose fermentation. Symptoms may include painful urination, frequent urge to urinate, pelvic discomfort, and in more severe cases, the presence of gas can be detected on abdominal X-rays or CT scans. Keywords: Emphysematous cystitis; urinary tract infection; diabetes mellitus; urinary catheter.

Background Diabetes mellitus (DM) is a prevalent predisposing factor for urinary tract infections (UTIs). Among hospitalized patients with acute pyelonephritis, UTIs are more common, severe, and associated with worse outcomes, particularly in those with type 2 DM. Pyelonephritis in DM patients is more frequently bilateral and linked to greater complications, with 90% of emphysematous pyelonephritis (EMPN) and cystitis cases occurring in diabetic individuals. Objective This study aims to evaluate the clinical and microbiological profiles, treatment outcomes, and complications of acute pyelonephritis in patients with type 2 DM. Methods A six-month prospective observational study was conducted from March 2016 to August 2016 at Stanley Medical College and Hospital, Chennai, India. A total of 102 hospitalized patients presenting with symptoms suggestive of acute pyelonephritis were included. Data were collected using a clinical questionnaire and analyzed using IBM SPSS Statistics for Windows, Version 20.0 (Released 2011; IBM Corp., Armonk, New York, United States). Patients received culture-sensitive antimicrobial therapy, percutaneous drainage, and renal replacement therapy as required. Results Out of 102 patients, 80 (78.4%) had non-emphysematous pyelonephritis (NEMPN), and 22 (21.6%) had EMPN. The mean age was 55.2±10.9 years, with a female predominance of 63 (78.4%) participants. Escherichia coli was the most common organism isolated in 70 (68.6%) cases. Renal dysfunction was present in 67 (65.7%) patients, with a higher prevalence in EMPN (22, 100%) compared to NEMPN (45, 56.3%) (p<0.001). Mortality was observed in three (3.9%) patients, and 25 (24.5%) developed de novo or progressive chronic kidney disease. Conclusion Early diagnosis and aggressive management of EMPN in type 2 DM patients improve outcomes. Acute pyelonephritis is predominantly observed in women, with fever and loin pain as the most common symptoms. Escherichia coli is the primary pathogen, and renal dysfunction is frequent but often reversible. Mortality is low with appropriate management.

Náhodný nález emfyzematózní cystitidy u 93letého diabetika s tumorem močového měchýře. Na akutní urologickou ambulanci se dostavil 93letý pacient stěžující si na obtékající permanentní močový katétr a bolesti podbřišku. Mezi pro případ relevantní pacientovy diagnózy patřily velmi vysoce rizikový uroteliální karcinom močového měchýře po opakovaných transuretrálních resekcích a recentně také výplaších intravezikální chemoterapií, diabetes mellitus druhého typu na dvojkombinaci perorálních antidiabetik a recidivující močové infekce. Pro suspekci na perforaci močového měchýře či komunikaci močového měchýře se střevem, při sterkorálně zapáchající moči, bylo doplněno kontrastní CT s vylučovací fází a CT cystogram. Perforaci či píštěl jsme neprokázali, avšak na základě zobrazovacích vyšetření jsme stanovili diagnózu emfyzematózní cystitidy. Tato kazuistika má za cíl upozornit na tuto vzácnou, mnohdy nenápadně se projevující, avšak potenciálně život ohrožující urologickou nosologickou jednotku. Emfyzematózní cystitida, uroteliální karcinom močového měchýře, intravezikální chemoterapie, diabetes mellitus, počítačová tomografie.

Emphysematous cystitis is a rare complication that can occur as a result of a lower urinary tract infection. Diabetic patients are at a heigh risk of developing emphysematous cystitis due to their susceptibility to urinary infections caused by gas-producing bacteria. The recommended diagnostic test for this condition is a computed tomography (CT) scan, which is effective in identifying gas buildup in the bladder wall and lumen. The prognosis of this condition depends on how quickly it is treated. In this report, we describe a woman with diabetes mellitus type-2 presented with emphysematous cystitis. Fortunately, she was treated with a combination of antibiotics, insulin therapy, and bladder drainage.

Sodium-glucose cotransporter 2 inhibitors and emphysematous cystitis.

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.

Emphysematous cystitis is a severe acute inflammation of the bladder characterized by the production of gas, mainly caused by infection with E. coli and Klebsiella pneumonia. It is primarily found in older diabetic females. Clinical presentation varies widely, and confirmation is typically obtained through radiology. Treatment involves prolonged antibiotic therapy and bladder drainage. The prognosis varies from patient to patient.

Background: The adjustment of immunosuppressive therapy after kidney transplantation (KT) to avoid graft rejection remains an important challenge for clinicians. It is difficult to achieve a good balance between under-immunosuppression (with an increased risk of graft rejection) and over-immunosuppression (with an increased risk of side effects) by only relying on the available information about immunosuppressive drugs (IMS). Immunobiogram® (IMBG) is a novel in vitro diagnostic test that provides clinicians with information about the patient’s sensitivity to individual IMS. Objective: To present a case report of a patient with renal transplant in the maintenance phase who presented several complications probably related to the immunosuppression during the follow-up, where the use of IMBG as complementary information helped clinicians to guide the therapeutical decision. Methods: IMBG is a first-in-class in vitro immunoassay that involves the culture of the patient peripheral blood mononuclear cells (PBMCs) in a semi-solid 3D matrix, then submitted to immune stimulation. It reveals the capacity of an IMS over a gradient to inhibit the activation of immune cells. The read-out allows the building of a dose-response curve per IMS tested, which is mathematically analyzed by a software using the key curve parameters and finally to be translated into a sensitivity map to IMS. Findings: We present a case report of a 72-year-old patient with a cadaveric donor kidney transplant receiving standard immunosuppressive treatment with mycophenolate, tacrolimus, and corticosteroids. The patient presented several episodes of infections during the follow-up (SARS-CoV2, Cytomegalovirus, spondylodisquitis by Staphylococcus aureus, and emphysematous cystitis) which were managed with different treatment adjustments such as de-escalation of mycophenolate and switching to mTOR. The information provided by the IMBG showed a lack of sensitivity to mTOR which allowed to confirm the final adjustment to a treatment with tacrolimus and corticosteroids, remaining the patient stable since then. Discussion: Despite various adjustments to the immunosuppressive therapy during the follow-up, the patient continued experiencing adverse effects that could be related to an over-immunosuppression state. The IMBG provided pharmacodynamic information that complemented the clinical and pharmacokinetic data available, facilitating the individualization of the treatment. Conclusion: The case highlights the potential of the IMBG as a complementary clinical tool for personalized treatment of kidney transplant patient management.

Hepatic portal venous gas (HPVG) is the presence of air bubbles in the portal vein and its branches. Traditionally it was considered a lethal condition because the main etiology was bowel ischemia. However, with the extensive use of diagnostic tools, it became clear that the causes of this condition are diverse and may include, but are not limited to, bowel necrosis. Here, we present a rare case of HPVG in an elderly dialysis patient with diabetes mellitus, initially diagnosed by ultrasound and CT scan. Our patient experienced abdominal pain, dysuria, oliguria, and other urinary symptoms starting three weeks prior. After considering all diagnostic tools and correlating them with the patient's history, clinical findings, and follow-up, the underlying cause of the HPVG was determined to be emphysematous cystitis. We concluded that the presence of HPVG in the initial screening test should prompt a comprehensive investigation to determine the cause, as a rare condition like emphysematous cystitis can result in HPVG.

Spontaneous rupture of the urinary bladder (SRUB) secondary to emphysematous. Cystitis (EC) in diabetic patients is extremely rare. Emphysematous cystitis is a relatively rare disease entity characterized by intramural and/or intraluminal bladder gas best depicted by cross-sectional imaging. Its disease mechanism is not well understood. Case report: A 61-year-old diabetic woman presented to the emergency department with diffuse abdominal pain and hematuria of tree hours duration. Physical examination revealed generalized abdominal tenderness. Multi-slice abdominal and pelvic CT scans showed parietal pneumatosis of bladder and communicating continuity solutions with a pre-vesical collection (extravasation of PDC into the collection). After proper resuscitation, the patient was transferred to the operating room for exploratory laparotomy. A thickness bladder rupture was noted, which was repaired. Conclusions: SRUB in patients with poorly controlled diabetes and EC is highlighted in this case study. Urinary bladder rupture secondary to EC should be considered when a diabetic patient with a history of urinary symptoms presents with an acute onset of abdominal pain. Uneventful recovery from SRUB is dependent on early diagnosis and treatment.

Emphysematous cystitis is a relatively rare form of urinary tract infection. A 72-year-old man with diabetes mellitus and long-term indwelling urethral catheterization was diagnosed with emphysematous cystitis. The clinical findings were resolved by conservatively managing the patient with antibiotics. However, cystoscopy subsequently revealed a yellowish-white soft tissue mass in the bladder, which was unlikely to be a bladder tumor. The mass could not be removed easily and frequently caused urinary catheter obstruction. We successfully removed this mass by performing transurethral resection twice. Through histopathological examination, the mass was identified as necrotic tissue comprising bacteria, fibrin, and suspected bladder mucosa.