Case report: Emphysematous cystitis may suggest ‘poor prognosis’ in Crohn’s patient
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The first reported incident of emphysematous cystitis in a patient with severe Crohn’s disease, without UTI or fistulizing disease, may signal “poor prognosis” for these patients, according to a case report published in BMC Gastroenterology.
“There have been multiple reports of [emphysematous cystitis (EC)] in the setting of infectious colitis, both with and without any microbiological evidence of a concurrent UTI,” S. M. Mahmudul Hasan, of Memorial University of Newfoundland, and Baljinder S. Salh, of Vancouver Coastal Health, wrote. “Acute colonic inflammation from diverticulitis has also been associated with EC, some cases of which were in the context of fistula formation between the colonic diverticula and the bladder. In the absence of obvious colovesical fistula, the connection between colonic inflammation and EC is poorly understood.”
In this case, a 43-year-old Taiwanese woman presented to Vancouver General Hospital with a two-month history of bloody diarrhea, consisting of 8-12 bowel movements per day, with associated abdominal discomfort and fatigue. During that time, she lost 10 kg and developed peripheral edema.
The patient did not have known risk factors for EC, such as diabetes, severe immunodeficiency, systemic infection, hematuria or intra-abdominal instrumentation.
Physical examination revealed a large perianal ulcer, which had developed two weeks before presentation, as well as multiple shallow ulcers on her abdomen. A contrast-enhanced CT scan of her chest, abdomen and pelvis showed a large heterogeneous soft tissue mass on the left thyroid lobe and circumferential mural thickening of the entire colon with multiple pseudopolyps. There were no remarkable findings in the bladder and no evidence of fistulous tracts, which was confirmed with MRI.
The patient also underwent a colonoscopy, which revealed hyperemic and ulcerated areas with pseudopolyps throughout the right, transverse and left colon; colonic biopsy confirmed Crohn’s colitis. An endobronchial ultrasound-guided biopsy of the mediastinal mass was diagnostic for nonmalignant goiter.
Treatment included IV cephalosporin, methylprednisone, infliximab and eventual subtotal colectomy with end ileostomy, due to colonic perforation.
“In this case report we describe the first case of EC in the setting of severe Crohn’s colitis,” the authors wrote. “EC has been shown to be complication of various colonic inflammatory processes. We suggest the severity of colitis in our patient was the main precipitating factor for EC.
“Radiological modalities can offer a noninvasive assessment of disease severity in [inflammatory bowel disease]. We propose that concomitant EC in decompensated IBD patients may be a marker of severe inflammation that portends poor prognosis.”
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