Emphysematous cystitis (EC) is the presence of intramural gas, with or without luminal gas, within the bladder as a result of a primary infection of the lower urinary tract with a gas-producing organism. The spectrum of clinical presentation of EC is non-specific and can range from minimally symptomatic urinary tract infection (UTI) to a scenario of peritonitis and septic shock [1]. Here, we report a case of subcutaneous emphysema due to EC based on a clinical diagnosis confirmed using computed tomography (CT).
Case report
An 81-year-old lady with poorly controlled non-insulin dependent diabetes presented to our accident and emergency department with increased frailty and confusion following review by her GP. She had been discharged 10 days earlier following treatment for a lower respiratory tract infection. In view of her deterioration, her GP was concerned that her decline may have been attributable to an occult infection or neoplasm. She was observed to have bilateral pitting oedema. On assessment in hospital, the patient was described as being "cushingoid" in appearance, and there was generalised crepitus on abdominal palpation to the infra-mammary region. The remainder of the clinical examination was unremarkable.
A CT scan was requested to define the aetiology of the clinical findings. The CT scan demonstrated a hugely distended bladder with an air fluid level and intramural gas (Figure 1a). In addition, gas was observed in several other bodily compartments; in the anterior abdominal wall (Figure 1b), intra-abdominal but extra-peritoneal (no free intraperitoneal gas), infra-peritoneal (within the pelvis), and the femoral canal (Figure 1c).
A urine culture grew Escherichia coli (E. coli), and on the basis of sensitivities the patient was started on a course of gentamicin and ciprofloxacin. Over the ensuing 2 days she continued to deteriorate, and the white cell count remained raised (WCC 13.5 × 109/l). On the advice of the on-call surgical team and the consultant microbiologist, the antibiotic regimen was changed to intravenous ceftazidine and metronidazole with oral cefalexin. Although it was a possibility, there was no evidence to suggest the presence of an enterovesical fistula, and her physical frailty precluded invasive investigation.
Three days later she developed right-sided pneumonia, for which she was started on a course of oral clarithromycin. In consultation with family it was decided to treat the patient conservatively. All intravenous antibiotics were stopped, and the patient passed away 5 days later (a total of 21 days after her most recent admission).
Prior to this admission and above diagnoses, the patient's other significant medical history included essential hypertension, diverticulosis, leg cramps, orthostatic pedal oedema, previous mastectomy of the left breast for invasive ductal carcinoma, right delta shoulder joint replacement following a rotator cuff tear and hiatus hernia. She was on once daily glimerpiride 4 mg, simvastatin 40 mg, quinine sulphate 300 mg, amiloride 50 mg and frusemide 40 mg; twice daily loperamide 2 mg, metformin 1 g and ranitidine 150 mg; and three times daily metoclopramide 10 mg and temezepam 10 mg pro re nata.
