Article / Case Report

"An Unusual Case of Emphysematous Cystitis in Non Diabetes Metastatic Lung Cancer Patient Undergoing Chemotherapy"

Marwane Andaloussi Benatiya1, Ghizlane Rais²*

1Department of Urology, Hassan 2 Hospital, Agadir, Morocco

2Department of Medical Oncology, Regional Center of Oncology, Agadir, Morocco

*Corresponding author: Rais Ghizlane, Medical Oncology Department, Regional Center of Oncology, Agadir, Morocco. Email:

Received Date: 06 June, 2018; Accepted Date: 15 June, 2018; Published Date: 25 June, 2018

1.       Abstract

Emphysematous cystitis is a rare and severe infection of the bladder wall and/or lumen that causes gas accumulation in the tissues. The gas is mainly produced by gram-negative bacteria such as Echirichia coli or fungal pathogens. Emphysematous cystitis most often occurs in older women with poorly controlled diabetes. Its has fulminating course, and can be fatal if not recognized and treated promptly. 

We report a case of a 45-year-old male, under chemotherapy for metastatic lung cancer, presented with fever, dysuria, and pneumaturia. Emphysematous cystitis diagnosed by a computed tomography scan.The treatment was based on antibiotics associated with bladder drainage.

The purpose of presenting this case report is not only to report an uncommon case of emphysematous cystitis but also to raise awareness among clinicians that this rare entity can occurs in non diabetes patients, during chemotherapy

1.       Introduction 

Emphysematous Cystitis (EC) is a relatively rare disease characterized by the presence of gas in the bladder wall and/or lumen. The primary risk factor of emphysematous cystitis is diabetes mellitus [1]. Other risk factors include neurogenic bladder, urinary tract outlet obstruction, chronic urinary tract infections UTIs, indwelling urethral catheters, and immune-deficiency [2]. The spectrum of clinical presentation of EC is non-specific and can range from minimally symptomatic urinary tract infection to a scenario of peritonitis and septic shock [3]. The occurrence during chemotherapy and the absence of medical history of diabetes or other risk factor often reported in the literature, are two remarkable characteristics described in this case report. 

2.       Observation 

Patient presented to our departement with three days history of fever, chills, dysuria and peneumaturia. In his past medical history, we don’t find notion of mellitus diabetes. He had a 25-year history of tobacco use, smoking one pack of cigarettes per day, but had no additional risk factors. He was followed in medical oncology department for metastatic lung cancer undergoing palliative chemotherapy with Paclitaxel-Carboplatin protocol. He was on day13 of the third cycle of chemotherapy. 

Physical examination revealed a temperature of 39C, normal blood pressure and a pulse rate of 95 bpm. On palpation, we found a hypogastric sensitivity. The patient’s urine was dark and cloudy. Cardiac and pulmonary examinations were unremarkable. Laboratory evaluation showed a normal glucose level of 1,1g/dl. Blood count revealed 19.000 white blood cells/mm3, hemoglobin 9,3gm/dl, sodium 132mmol/l, potassium 4,5mmol/l, Chlorid 80mmol/l. The C-Reactive Protein (CRP) was160 mg/dl. The transaminase enzyme levels were normal. Urine analysis revealed cloudy urine, pH 5,5 with numerous white and red blood cells on microscopy. The diagnosis of emphysematous cystitis was made based on the CT scan. Abdomino -pelvic image showed presence of intraluminal gas and thickening of the bladder wall (Figure 1,2). There were no findings of ureteral obstruction or pyelonephritis. He was empirically treated with association of ciprofloxacine and ceftriaxone and he was catheterized with an 20 Fr Foley catheter.

The patient’s clinical status improved. He became afebrile and decline in his white cell count on day 3 and his catheter was removed on day 15. Urine culture grew Eschirichia coli, and based on sensivities, he continued antibiotics with Ciprofloxacine. A repeat urine culture was sterile on the 20th day of the antibiotic treatment then refered to medical oncology department to continue his cancer care. 

3.       Discussion 

Emphysematous cystitis (EC) as within the urinary tract was initially described in 1671, in the case of a man presenting with pneumaturia [4]. Although rare, these infection is more common than is suggested by the approximately 200 cases that are currently documented in the literature as case reports and cases series [5]. The pathogenesis of EC is not completely understood. Elevated tissue glucose levels in diabetic patients may provide a more favorable microenvironment for gas-forming microbes. However, bacterial gas production does not fully explain the pathologic and clinical manifestations of emphysematous UTIs [5,6]. 

On reviewing the literature on EC, persons at risk of the disease are the elderly women (most patients were over age 60), diabetics and patients with an immunosuppressive co-morbidity and/or urinary tract outlet obstruction, such as a neurogenic bladder [1,6]. To the best of our knowledge, our case is the first report of emphysematous cystis occuring during cancer treatment by chemotherapy. Our patient has received three cycles of chemotherapy according Paclitaxel-Carboplatin protocol. Severe infections associated with this association and reported in several phase III trials are around 5%. 

The presentation of EC varies widely, ranging from asymptomatic features to septic shock [1-6]. A pathognomonic sign of circumferential, acoustic shadowing around the bladder wall is rarely noted. According toa literature review, the most frequent symptoms and findings on physical examination are abdominal pain, pneumaturia after catheterisation and urinary retention, noted 80%, 70% and 60% of the patients, respectively [8]. In this case, our patient was in immunosupressive condition caused by chemotherapy and presented with fever, dysuria, and pneumaturia which strongly suggested the diagnosis of emphysematous cystitis. 

As reported in the literatture, two-thirds of EC are caused by E. coli; the remaining third are caused by Enterobacter species, Clostridium species, Klebsiella pneumonia, Staphylococcus aureus, or Proteus mirabi, Candida species may also be responsible [1,3,9]. The pathogen agent in our case was E. coli, which was sensitive to Ceftriaxone and Quinolones. The diagnosis of EC is established by radiological findings. Every patient with urinary tract infection who seems to be severely ill should have preferably a pelvic C scan to detect emphysematous complications. EC is aggressive and has a good prognosis with rapid healing when appropriately treated. A delay in diagnosis may cause bladder rupture, septicemia, peritonitis and death. Failure to recognize or diagnose this condition early in the course of the infection increases the associated mortality rate by up to 10% [1,3,9]. 

 Treatment of EC consists of the administration of antibiotics which should be adjusted to the results of urine culture, bladder drainage and the treatment of co-morbid disorders. Endovenous antibiotics, such as flouroquinolones, penicillin with beta-lactamase inhibitors and third generation cefalosporines, are some of the appropriate treatments. Antifungal agents may be used in cases of a fungal infection. In different published cases, the duration of treatment varied from 1 to 3 weeks [6-11].

Surgical interventions, such as debridement or partial cystectomy, may be required for patients who respond poorly to antibiotics or have necrotizing tissue [10,11]. The prognosis of EC is generally good with an improvement of the patient's condition within the first week. Complications are noted in 10-20% and the mortality rate is low (7%) [1,6,7].

4.       Conclusion

This unsual case reveal that emphysamatous cystitis can occur on patient during chemotherapy treatment without other risk factors such as DM. Physicians should be alert to signs of these potentially fatal infections and diagnosis should be followed by the appropriate combination of medication and surgical intervention, if needed.

Figure 1: CT scan of the pelvis showing gas in the bladder and the bladder wall.

Figure 2: Pelvic computed tomography demonstrating emphysematous changes in the bladder wall.

1.       Thomas AA, Lane BR, Thomas AZ, Remer EM, Campbell SC, et al. (2007) Emphysematous cystitis: a review of 135 cases. BJU Int 100: 17-20.

2.       Mokabberi R, Ravakhah K (2007) Emphysematous urinary tract infections: diagnosis, treatment and survival (Case review series). Am J Med Sci 333111-333116.

3.       Bracq A, Fourmarier M, Bourgninaud O, Boutemy F (2004) Emphysematous cystitis complicated by bladder perforation: diagnosis and treatment of a rare case. Prog Urol 14: 87-89.

4.       Holesh S (1969) Gas in the bladder. Cystitis emphysematosa. Clin Radiol 20: 234-236.

1.       Gargouri MM, Abid K, Kallel Y, Rhouma SB, Chelif MY (2015) Nouira Severe sepsis secondary to emphysematous cystitis . African Journal of Urology 21 : 41-43.

2.       Pérez Fentes D, Blanco Parra M, Lema Grille J, Toucedo Caamano˜ V, Novás Castro S, et al. (2009) Emphysematous cystitis: casereport. Arch Esp Urol 62: 392-395.

3.       Rosell R, Gatzemeier U, Betticher DC, Keppler U, Macha HN, Pirker R, et al. (2002) Phase III randomised trial comparing paclitaxel/carboplatin with paclitaxel/cisplatin in patients with advanced non-small-cell lung cancer: a cooperative multinational trial. Annals of Oncology 13: 1539-1549,

4.       Holesh S (1969) Gas in the bladder. Cystitis emphysematosa. Clin Radiol. 20: 234-236.

5.       Grupper M, Kravtsov A, Potasman I (2007) Emphysematous cystitis: illustrative case report and review of the literature. Medicine (Baltimore) 86: 47-53.

6.       Perlmutter AE, Mastromichaelis M, Zaslau S (2004) Emphysematous cystitis: a case report and literature review. W V Med J 100: 232-233.

7.       Selley JK, Kane BG, Kane KE (2010) Importance of obtaining a detailed medical history in diagnosing emphysematous cystitis. J Am Osteopath Asso 110: 91-94.

8.       Reese AC, Stoller ML (2010) Emphysematous cystitis Urology. 75 : pp. 1315-1316

Citation: MA Benatiya, G Rais (2018) An Unusual Case of Emphysematous Cystitis in Non Diabetes Metastatic Lung Cancer Patient Undergoing Chemotherapy. Emerg Med Inves: EMIG-178. DOI: 10.29011/2475-5605. 000078