Emphysematous Cystitis: An Exuberant Case

Emphysematous cystitis is a rare but underrecognized urinary tract infection characterized by gas formation within the bladder wall and lumen. It predominantly affects patients with predisposing factors such as immunosuppression and underlying urinary tract abnormalities. Delayed diagnosis may result in severe complications, including bladder necrosis, perforation, and septic shock. We describe the case of an adult female with an undifferentiated autoimmune disease under long-term corticosteroid therapy and known urinary tract dysfunction, who presented with prostration, abdominal pain, vomiting, and decreased urine output. She rapidly deteriorated into septic shock with multiorgan dysfunction involving the cardiovascular, renal, neurological, and hematological systems. Laboratory findings revealed markedly elevated inflammatory markers and severe acute kidney injury. Computed tomography (CT) of the thorax, abdomen, and pelvis demonstrated emphysematous cystitis with extensive gas tracking into the retropubic and extraperitoneal spaces. A contrast-enhanced study excluded bladder rupture. Broad-spectrum antimicrobial therapy and intensive supportive care were initiated and later tailored based on microbiological cultures isolating Klebsiella pneumoniae and Enterococcus faecalis. The patient showed progressive clinical, laboratory, and radiological improvement with prolonged conservative management, avoiding surgical intervention. This case illustrates an unusually extensive radiological presentation of emphysematous cystitis in an immunosuppressed patient with structural urinary tract abnormalities. CT played a pivotal role in diagnosis, exclusion of bladder rupture, and guidance of therapeutic strategy. Despite a severe initial presentation, early multidisciplinary management enabled a favorable outcome without surgical intervention. Emphysematous cystitis should be considered in septic patients with urinary symptoms and relevant risk factors. Prompt imaging, early targeted antimicrobial therapy, and close multidisciplinary follow-up are crucial to reduce morbidity and mortality, even in severe presentations.