Management of Emphysematous Cystitis in the Intensive Care Unit

Emphysematous cystitis (EC) is a complication of urinary tract infection (UTI) caused by gas-forming bacteria within the walls and lumen of the urinary bladder. We discuss here a case of a 55-year-old woman with uncontrolled diabetes mellitus, who received multiple courses of antibiotics for dysuria and who presented with altered mental status, hypotension, and hypoglycemia. Initially, the patient was managed with resuscitation, intravenous antibiotics, and supportive care. Eventually, she required vasopressors and was transferred to the Intensive Care Unit. Blood culture revealed Proteus mirabilis. CT abdomen and pelvis showed gas within the bladder wall along with new-onset left-sided pleural effusion. During the hospital stay, the patient's vasopressor requirements escalated. She required invasive positive pressure ventilation and continuous venovenous hemodialysis due to worsened respiratory status and severe metabolic acidosis. The Urology Department determined that she was not a surgical candidate. Given her poor prognosis, the patient's care was shifted to comfort measures only. This case highlights that EC in uncontrolled diabetics may present atypically with hypoglycemia rather than hyperglycemia, can be complicated by polymicrobial bacteremia and pleural effusion, and may progress to death despite maximal medical therapy. Clinicians should suspect EC in uncontrolled diabetics with hypoglycemia and septic shock. The presence of polymicrobial bacteremia or pleural effusion predicts a rapidly progressive and worse prognosis. When surgical intervention is not possible, mortality remains high despite aggressive medical management. Early urology consultation for possible cystectomy is essential before multiorgan failure ensues.