A case of alcohol-related emphysematous cystitis

Emphysematous cystitis (EC) is a very rare urinary tract infectious disease that can be fatal if not treated. In general, it frequently occurs in diabetic women and is thought to be associated with gas-producing bacteria. Type 2 diabetes mellitus, immunosuppression, drugs (mostly steroids), neurogenic bladder and instrumentation are the major risk factors of this type of infection. We present a case of emphysematous cystitis in a 53-year-old male, in which the patient does not have any classical risk factors associated with EC other than alcohol consumption. To the best of our knowledge, the only case in the literature where this type of infection develops without a classical risk factor and negative urine culture. It is also one of the rare EC cases that may be associated with alcohol use.

toms.: The patient had no pathological sign on physical examination. The laboratory tests: his serum biochemical parameters were normal, the Prostate-specific antigen level was 0,78 and urinalysis was positive for red blood cells and nitrite. Urine culture was negative for bacteria and fungi. Post voiding residual urine and peak flow were 58 and 24 respectively. Urinary system USG: there was a clear image of intramural and intraluminal gas (Fig.1). The patient had no urological operation for any symptom and had no risk factors for this type of infection. His previous urine cultures were negative twice before being admitted to our hospital.
An abdominopelvic computed tomography was performed in order not to miss any coexisting pathology as the patient had no risk factors for this type of infection. Abdominopelvic computed tomography reported as the patient had only EC, and no other abdominal pathology such as bowel perforation, enterovesical fistulas, diverticulosis, Crohn disease or rectosigmoid colonic carcinoma (Fig. 2 The patient was consulted on infectious diseases and immunology departments. The suggestion was not to use antibiotics as urine culture was negative. The patient was treated symptomatically, prescribed an antimuscarinic agent and 550 mg oral naproxen sodium once per day. A single dose of 40 mg intramuscular prednisolone injection was used to cease the progression of inflammation. We advised the patient not to take alcohol during the rest of the treatment.
Results. After 1 week of medical treatment, the patient came to our polyclinic for control. His lower urinary tract symptoms have resolved. He was appointed for another control for radiological evaluation.
After 2 months of medical treatment, the patient came to our polyclinic for his second control. We performed urinary system ultrasonography and found that the patient had a complete recovery of gas accumulation as an air-fluid level in the bladder lumen and wall were absent. The only remaining radiological pathology was minimal bladder wall thickening (Fig. 3). Discussion. EC is an uncommon urinary tract infection that was first reported in a human body in 1961 [6] and characterized as the presence of gas in the bladder wall or bladder lumen. EC is common in especially >65 age population, other known risk factors are female gender and type 2 diabetes mellitus in patients [5] [7]. 87 % of these patients had type 2 diabetes mellitus and other urological disorders [7].
In our case, the patient was a non-diabetic middle-aged man with none of the risk factors mentioned above and had overall good health status. We could not clearly identify the etiology of the infection in this patient because he had no gas-producing bacteria in the urine culture and there were no known risk factors but alcohol consumption.
A single dose of intramuscular prednol, followed by a daily NSAID tablet and antimuscarinic has resolved his symptoms in one week, and all radiological evidence was absent in two months. Since the only etiological factor of this patient is alcohol consumption, this suggests that removal of this single risk factor might have improved the prognosis.
To the best of our knowledge, the only case in the literature where this type of infection develops without a classical risk factor and negative urine culture is this one [9]. It is also one of the rare EC cases that may be associated with alcohol use. Alcohol metabolism is known to modulate the cellular response to LPS in the liver and independently generate endogenous inflammatory inducers. Thus, both alcohol and LPS act simultaneously to influence the inflammatory response in the liver and other organs, including bladder [10,11]. Aasems Jacob et al. and M. Al-Assiri et al. identified the alcoholrelated EC in a patient with pancreatitis. In their study, the simultaneous effect of alcohol on multiple organs was observed [12,13].
Conclusions. We suggest that EC can occur in the absence of gas-producing bacteria, without any classical risk factors, and may initially manifest itself as mild lower urinary tract symptoms such as painful urination in our case.