Content area
Full text
Background
Emphysematous cystitis (EC), characterised by air within the bladder wall, is a rare diagnosis. The underlying disease is usually caused by anaerobic bacteria. Prompt diagnosis and treatment are warranted to prevent the potential mortality of this infectious condition. Owing to increased use of radiological imaging, emphysematous conditions are more often diagnosed. Previous reports have described the association of Clostridium difficile infection to pneumatosis intestinalis. We present a patient with recurrent C. difficile infection that provoked pseudomembranous colitis-associated EC.
Case presentation
A 78-year-old woman was transferred from her nursing home to the outpatient clinic. She was admitted because of progressive abdominal cramping and diarrhoea for past 2 days. She had a history of long-standing obstipation and non-insulin-dependent diabetes. An open cholecystectomy had been performed in the past. She was recovering from a stroke, 2 months before. Owing to the vascular incident, she had difficulty comprehending our questions and explaining her illness.
Vital signs on admission showed a blood pressure of 137/92 mm Hg, a heart rate of 120 bpm and an afebrile temperature. Physical examination revealed a diffuse abdominal tenderness throughout the left side and a mild flank pain. Laboratory findings showed marginal increased inflammatory markers with a C reactive protein of 28 mg/L, erythrocyte sedimentation rate of 12 mm/h, and a white cell count of 22.1x109 /L. There were no signs of liver or kidney failure. Direct examination of urine was negative for urinary tract infection.
At the internal ward she deteriorated and bowel sounds, which had been normal on the day of admission became absent. An 'acute abdomen' developed and intestinal ischaemia was suspected. An emergency laparotomy showed no signs of ischaemia. Postoperatively, she was admitted to the intensive care unit (ICU). The following days, abundant diarrhoea persisted. An abdominal CT scan and a total colonoscopy were performed.
Investigations
The abdominal CT scan demonstrated extensive wall thickening of the transverse colon suspected for colitis; there was also the presence of gas in the peritoneum and multiple gas-filled cysts within the wall of the bladder ( figure 1 ). A colonoscopy revealed multiple irregular ulcerations covered with pathognomonic fibrinous pseudomembranes and mucosal oedema in the descending colon, sigmoid and rectum ( figure 2 ). The colonic biopsy revealed signs of non-specific mild inflammation...