emphysematous cystitis is a distinct complicated lower urinary tract infection ( uti ) characterized by air within the bladder wall and lumen .
patients with chronic utis , indwelling urethral catheters , urinary tract outlet obstruction , or neurogenic bladders are predisposed to complicated utis such as emphysematous cystitis .
air within the urinary tract can also occur due to instrumentation , fistula to a hollow viscus , tissue infarction with necrosis .
patients might have varied presentations , ranging from incidental diagnosis on abdominal imaging to severe sepsis .
gas - forming infections or emphysematous conditions of the urinary tract are potentially life - threatening , and require prompt evaluation and management .
we describe a case of emphysematous cystitis that was managed successfully with bladder drainage , intravenous antibiotics , and strict glycemic control .
a 45-year - old male who was a known case of type-2 diabetes mellitus for last 16 years , complained of on and off fever , dysuria and turbid colored urine for last 3 months .
he had past history of suprapubic catheterization for obstructive uropathy due to meatal stenosis 15 years back . clinical examination revealed pallor , penile hypospadias , meatal stenosis , bilateral nonproliferative diabetic retinopathy and evidence of sensory neuropathy .
investigations showed anemia ( hb7.7 gm / dl ) , neutrophilic leukocytosis ( total leukocyte count 19800 cells / cmm ( n , 400011000 cells / cmm ) with 90% neutrophils .
serum creatinine was 3.5 mg / dl ( n , 0.6 - 1.2 mg / dl ) and hba1c was 8.5%
ct abdomen revealed intraluminal and intramural gas in the bladder with thickening of bladder wall [ figure 1a  c ] .
kidneys were normal in size and shape and there was no perinephric stranding or gas in renal parenchyma or renal pelvis .
figure 1d shows disappearance of intramural and intraluminal gas on follow up ct imaging after 8 weeks .
serum creatinine was decreased to 2 mg / dl , but not normalized probably because of underlying diabetic nephropathy .
( c ) axial ct image through lower pelvis showing pneumobladder , intramural air and circumferential mural thickening .
( d ) axial ct image through lower pelvis after treatment showing disappearance of air ; however , mural thickening is persisting
other organisms reported include klebsiella pneumoniae , pseudomonas aeruginosa , proteus mirabilis , candida albicans , and candida tropicalis , aspergillus fumigatus , staphylococcus aureus , group d streptococcus , enterococcus faecalis , enterobacter aerogenes , and clostridium perfringens and cl .
the clinical presentation of emphysematous cystitis is varied ; patients can be asymptomatic , describe pnematuria , or irritative voiding symptoms , or present with an acute abdomen with severe sepsis . of reported patients with emphysematous cystitis ,
predisposing factors for emphysematous cystitis include diabetes mellitus , neurogenic bladder , lower urinary tract obstruction , urethral catheter placement , vesicourethral reflex , and end stage renal disease .
the effects of diabetes mellitus on the urinary tract include diabetic nephropathy , renal papillary necrosis , renal artery stenosis , and bladder dysfunction secondary to neuropathy .
these factors combined with glycosuria and impaired leukocyte function place diabetic patients at greater risk of complicated utis such as emphysematous cystitis .
overall , two - thirds of reported cases of emphysematous cystitis were diabetic and 64% were women
. the symptoms of emphysematous cystitis are similar to those of uncomplicated cystitis , consisting of frequency , urgency , and dysuria .
therefore , a high index of suspicion is required for diagnosis especially in patients with risk factors .
plain radiographs of the abdomen reveal radiolucency within the lumen of the bladder as a ring of radiolucency outlining the bladder wall .
computed tomography of the abdomen is superior to plain radiographs as a diagnostic tool because it clarifies the extent and location of the gas collection as observed in our case .
a pathological assessment of involved bladder tissue might show bladder wall thickening with vesicles of varying size , and microscopically there are multiple gas filled vesicles predominantly within the bladder mucosa , lined by flattened fibrocytes and multinucleated giant cells .
it is thought that the high glucose concentration within the tissues acts as a favourable substrate for organisms to produce carbon dioxide through facultative anaerobic glycolysis .
however , this does not account for the significant number of non - diabetic patients with emphysematous infections . in such patients , urinary albumin might act as the substrate for gas production by urinary pathogens .
another theory suggests that an impaired host response , involving vascular compromise and impaired catabolism within the tissues , predisposes patients to gas production within these tissues . the pathogenesis is not yet fully understood , but a multifactorial aetiology of impaired host responses with sugar or protein fermentation seems to be a plausible explanation for the production of gas within the affected tissues .
management consists of adequate urinary drainage , appropriate antibiotic treatment , and good blood glucose control .
however , delayed diagnosis may lead to extension to the ureters and renal parenchyma , bladder rupture , and death .
the gas is reabsorbed once the infection is eliminated as was seen in our patient [ figure 1d ] .
history of pneumaturia and evidence of intraluminal and intramural gas along with bladder thickening on imaging clinches the diagnosis of emphysematous cystitis .
 emphysematous cystitis is a relatively rare clinical entity caused by gas - fermenting bacteria or fungus . 
 presentation is often nonspecific and imaging is the best diagnostic modality . 
 we report a case of a 45-year - old male who presented with fever , dysuria , and pneumaturia , and was found to have emphysematous cystitis . 