Emphysematous cystitis and emphysematous pyelitis: a clinically misleading association

We present a rare case of emphysematous cystitis associated with an emphysematous pyelonephritis in a diabetic Arab man who was admitted in a confusional state. A 60-year-old man was admitted to the emergency department with confusion and hypogastric mass. The Clinical examination found comatose patient with a mass in the tympanic hypogastric percussion. The pelvic computed tomography (CT) demonstrated intramural gas in the urinarytract, which suggested a diagnosis of emphysematous cystitis and emphysematous pyelitis. The treatment was based on an antibiotics associated with a bladder drainage and diabetes stabilization. The evolution was uneventful. Every diabetic patient with a urinary tract infection who seems to be severely ill should have an abdominal X-ray as a minimal screening tool to detect emphysematous complications. The rarity and the association with an emphysematous pyelitis, which is rarely reported in the literature, are two remarkable characteristics described in this case report.


Introduction
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 to a scenario of peritonitis and septic shock [1]. We report the case of EC associated with emphysematous pyelitis (EP) in a patient with diabetic tympani on hypogastric dullness.

Discussion
Emphysematous cystitis is a rare disease mostly in the patients in their late fifties. It is twice as frequent in women as in men [2]. It CO2 producing germs attack not only the glucose that is present in the urine of the diabetics, which causes air to appear in the bladder cavity, but also the glucose contained in the bladder parietal cells, which causes CO2 bubbles to appear inside the vesical wall [3].
Emphysematous cystitis associated with more extended urologic attacks together with the emphysematous ureteritis and emphysematous pyelonephritis or emphysematous prostates have been reported [2].
In our case, the EC was associated with an EP with a tympany to percussion hypogastric mass. Saw the failure of survey, cystostomy should be realized on a hypogastric mass tympany. We first realized a pelvic ultrasound that was inconclusive. An urinary tract X-ray without preparation which showed the presence of pelvic gas. We have completed on abdominopelvic CT scan without injection of intravenous contrast confirms the EC associated with EP. The Page number not for citation purposes 3 presence of a hypogastric mass in a patient with tympany is confused as misleading.
The diagnosis of EC is confirmed more often by radiography.
Therefore, radiography remains a cornerstone of positive and specific diagnosis of emphysematous cystitis. In view of the insights gained in a reclining patient, radiography without previous preparation of the abdomen shows a radio-transparent ring on the pelvis area, a pneumo bladder (edge clearly confirmed to the detrusor and dissecting the vesical wall) and a hydroaeric pelvic level [4]. The differential diagnosis is done with primitive pneumaturia defined by the presence of gas in the bladder and with or without passage into the urethra and, particularly, the communication of the bladder with hollow organs. The vesicodigestive fistulas (colic or grelic) can be diagnosed using the radiological digestive and vesical opacifications [2].
Treatment is based on three fundamental therapeutic principles: the first is drainage of the bladder using a transurethral probe or by supra pubic drain which removes the infected urine and gas, the upper urinay tract has not been drained because due to the lack of expansion; the second is taking samples and culturing the urine allows the institution of broad spectrum antibiotic treatment, which will be adapted by the data obtained. Initially the antibiotic therapy will be managed parenterally then replaced by oral medication to consolidate treatment. Finally, diabetes stabilization is necessary both for monitoring the condition and breaking the vicious circle the patient may find himself in. Hyperbasic oxygen treatment is not a standardized therapy attitude in this type of pathology, but it was associated with a clear clinical improvement [3].
The prognosis of EC and EP can be rather serious due to the therapeutic failures which can occur when there is an ignorance of the physiopathological mechanisms of EC and EP. Actually, the prognosis in the case of EC, EP remains good provided that it is diagnosed in time and that an effective treatment is started without any delay. In the event of serious sepsis, the disease can evolve into the complications of EC such as necrosis cystitis, emphysematous pyelonephritis, and despite antibiotic therapy, resuscitation and urine aspiration [5].

Competing interests
The authors declare no competing interests.