Emphysematous Cystitis in a Heart Transplantation Patient - A case report
Hsuan-Ting Kuo, Chin-Wei Yang, Sheng-Han Tsai, Chia-Lun Huang, Hsiao-Hsian Wang, Kuang-Kuo Chen, Luke S. Chang and Chieh-Chen, Hsieh
Department of Urology, Cheng Hsin General Hospital, Taipei, Taiwan
Introduction: Emphysematous cystitis is a rare presentation of complicated urinary tract infection. Herein we present a case of non-diabetic man with a history of dilated cardiomyopathy status post heart transplantation before, who was diagnosed of emphysematous cystitis.
Presentation of case: A 57-year-old non-diabetic man with a history of dilated cardiomyopathy status post heart transplantation five years ago and is currently under immunosuppressive agents with tacrolimus, mycophenolate mofetil and prednisolone, called at our emergency room due to fever up to 39.5 degree of Celsius with right flank pain. Blood investigation indicated leukocytosis with left shift pattern (16900 cells per cubic millimeter, 92.8 percent neutrophil) and elevated C-reactive protein level (2.17 milligram per deciliter). Urinalysis reported 20 to 29 white blood cells per high-power field. Non-contrast computed tomography scan of abdomen revealed intramural gas with diffuse fat stranding around the urinary bladder and right ureterovesical junctional stone complicated with right hydroureteronephrosis. Emphysematous cystitis was impressed. After empiric antibiotic treatment with flomoxef was given for 12 days, the patient received right ureteroscopic lithotripsy with ureteral catheter implantation.
Discussion: Emphysematous cystitis is a rare disease caused by gas-forming microbial infection. Diabetes is considered the commonest predisposing factor, with up to 70 percent of patient were reported diabetic. Other risk factors include old age, female gender and immunosuppressive status. After reviewing current literature available on PubMed from 1985 to 2020, there are only 35 organ transplant recipients presented with emphysematous urinary tract infection (34 cases of renal transplant and 1 case of bone marrow transplant). Most of the reported patients received immunosuppressive agents with combination of tacrolimus, mycophenolate mofetil and prednisolone, which is the same as our case. To the best of our knowledge, this is the first and only case that described emphysematous cystitis in a heart transplant patient. Clinicians should be aware that the immunosuppressive agents might be an important predisposing factor of emphysematous urinary tract infection.