Emphysematous cystitis on POCUS: A lines in the bladder wall – A rare case
Dr Himanshu Gul Mirani
Case Presentation:
Emphysematous cystitis is a potentially life-threatening complicated acute urinary tract infection with a mortality rate of up to 7-10%. It is often reported in elderly with history of diabetes. Early diagnosis and intervention with antibiotics can avoid complications like progression to emphysematous pyelonephritis or need for surgical intervention like bladder debridement or partial or total cystectomy.
The patient was managed along standard sepsis guidelines with intravenous antibiotics and fluids. Her hemodynamics stabilized and she was admitted under urology team.
Management and Outcome:
To highlight the role of point-of-care ultrasound (POCUS) in the rapid diagnosis of emphysematous cystitis, emphasizing its utility in emergency settings.
A 79-year-old woman presented with fever, dysuria, abdominal pain, and vomiting, with a background of poorly controlled diabetes, chronic kidney disease, and heart failure. On examination, she was conscious and
orientated, pyrexial with tachycardic, hypotensive, with normal saturation in room air. Her lower abdomen was tender, maximally in the suprapubic region. Venous blood gas had normal p H with base excess of minus 4 and lactate of 3 mmol/L. Point-of-care ultrasound was done by the emergency physician to look for evidence of urinary retention, assess for signs of cystitis like sedimentation within the bladder and
examine the upper renal tracts for hydronephrosis.
Incidentally, POCUS revealed several A lines in the bladder wall which had loss of well-defined borders. There was evidence of sedentation in the bladder. Given that there was no history of instrumentation or
catheterization, these findings were concerning for emphysematous cystitis. The patient had an urgent computed tomography (CT) scan abdomen & pelvis which confirmed gas locules in the bladder wall consistent with emphysematous cystitis. There was no evidence of upper urinary tract dilatation or gas.
Key Learnings and Points:
This is one of the first case reports from an emergency department that have demonstrated A-lines in the bladder wall, in a confirmed case of emphysematous cystitis. A-lines are horizontal, equidistant air
reverberation artefacts, commonly seen in thoracic ultrasound. Previously abdominal A-lines have been used to diagnose pneumoperitoneum.
In this rare case, localized A-lines in the bladder wall with dirty shadowing artefact of bladder wall on point-of-care ultrasonography, with associated sonographic (like sedimentation and debris within bladder) and clinical signs of cystitis raised the suspicion of emphysematous cystitis. This led to prompt treatment with
antibiotics and early definitive imaging.