AN INCIDENTAL CASE OF EMPHYSEMATOUS CYSTITIS Charles Woodall DO, Oriane Ezedine MD, Christopher Hayden MD, Calvin Rome MD, Kristi Boudreaux MD; Department of Medicine, LSU Health New Orleans, New Orleans, LA.
Introduction: Emphysematous cystitis (EC) is a rare and severe urinary tract infection (UTI) that is diagnosed by visualization of air in and around the urinary bladder wall and is most often found in conjunction with emphysematous pyelonephritis (EPN).
obtained and sent to the lab until approximately 24 hours after first receiving antibiotic therapy. Urinalysis was, not surprisingly, unremarkable for bacterial infection. She remained afebrile and free of urinary complaints throughout her hospital admission and was administered a single dose of Fosfomycin prior to discharge due to her previous history of ESBL E. coli UTI as well as allergies to Bactrim and Ciprofloxacin. Discussion: Escherichia coli and Klebsiella pneumoniae are the two most common gas- forming bacteria responsible for this condition and its characteristic presentation. Other pathogens such as Clostridium, Enterococcus, Proteus, and Pseudomonas are found less frequently, and cases caused by Aspergillus and Candida are rare. Risk factors commonly associated with EC include diabetes, neurogenic bladder, immunosuppression, and chronic infection. Presentation varies drastically with asymptomatic, incidental disease encompassing one end of the spectrum and severe, sometimes lethal, cystitis comprising the other. Severe disease is more closely associated with concomitant EPN. Regardless of symptom severity, broad-spectrum antibiotic therapy is indicated in all cases to prevent significant morbidity and even mortality.
Case: An 84-year-old female with type 2 diabetes mellitus, chronic kidney disease stage III-b, and constipation with previous fecal impaction presented with intractable nausea and vomiting for 1 day. The physical exam demonstrated a distended abdomen without significant tenderness. Pertinent labs included leukocytosis, microcytic anemia, and mildly decreased BUN. Abdominal Xray demonstrated significant stool burden in the rectum with a non- specific bowel gas pattern without any evidence of obstruction. Computed Tomography of the abdomen was then performed and revealed abnormal thickening of the walls of the rectum and parts of the sigmoid suggesting proctocolitis as well as abnormal thickening of the walls of the urinary bladder with air also seen in the walls suggesting emphysematous cystitis. The patient’s fecal impaction was successfully treated with digital dis-impaction, and she was treated with Zosyn while awaiting data from the urinalysis. Unfortunately, a urine specimen was not
P.O. TO PLEURAL POTASSIUM: A CASE OF ESOPHAGOPLEURAL FISTULA Hannah Zulli MD, Wayne Wheeler MD, Kalem Derouen BS, Briggs Welch MD, Nikki Arceneaux MD, Kyle Hoppens MD; Department of Medicine, LSU Health New Orleans, New Orleans, LA.
Introduction: Esophagopleural fistula is a condition associated with a high degree of morbidity and mortality. Symptomatology includes chest pain, dysphagia, and dyspnea. Risk factors are trauma, infection, and malignancy. This case details the discovery and management of an esophagopleural fistula. Case: A 52-year-old male with type 2 diabetes and gastroesophageal reflux presented for acute, right- sided chest pain. Cardiac work-up, included a normal chest x-ray (CXR). He was admitted for diabetic ketoacidosis (DKA) and surgical management of a gangrenous left foot. He underwent irrigation and debridement and resumed a diabetic diet following
the procedure. He soon after developed acute hypoxia requiring 15 liters of supplemental oxygen. CXR showed complete opacification of his left lung field. Thoracentesis drained 1 liter of straw-colored fluid with brief clinical improvement. A repeat CXR demonstrated re-accumulation of fluid. Thoracostomy tube was placed with immediate drainage of 2 liters of exudative fluid by analysis. The patient stabilized but continued to complain of retrosternal chest pain. A day later, his nurse administered orange-colored liquid potassium supplement and immediately noticed the same solution draining from his chest tube. Gastrograffin esophagram identified contrast
extravasation into the left thoracic cavity and esophagogastroduodenoscopy (EGD) revealed a 23
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