A 64-year-old Japanese man presented to our hospital with a 2-week history of high fever and difficulty in micturination. Before the visit, the patient has been diagnosed with pharyngitis and had been administered antibiotics (Levofloxacin) at another clinic. At the first visit, urinary retention was revealed with lower abdominal pain. His past medical history included DM and a brain infarction. Laboratory data revealed a white blood cell count of 6400, a hemoglobin level of 12.0 g/dL, a hematocrit of 36.0%, a platelet count of 26.9x104, a serum glucose level of 525 mg/dL, a HbA1c level of 7.3%, and a C-reactive protein (CRP) concentration of 12.0 mg/dL. A urine culture yielded Escherichia coli (108 CFU/mL). An abdominal radiography showed an accumulation of gas in the urinary bladder wall and lumen (Figure 1A). An abdominal computed tomography (CT) demonstrated bilateral hydronephrosis, air-fluid levels in the urinary bladder, and gas accumulation in the urinary bladder wall (Figure 1B).
According to these radiographic examinations, this patient was diagnosed with EC, and antibiotics (Meropenem Hydrochloride; 1.0 g/day) were started. The glucose levels were regulated with insulin. Continuous urinary drainage with a urethral catheter improved the upper urinary tract obstruction. Furthermore, a characteristic accumulation of air in the urinary bladder wall obviously decreased. Although the fever went down within four days, it increased again with an exacerbation of respiratory symptoms, including cough, sputum, and difficulty in breathing. Although the white blood cell count did not increase, the CRP concentration increased (Figure 2). Antibiotics were administered for another week because aspiration pneumonia was suspected from the results of a chest CT scan (Figure 3A). However, the patient's condition did not improve. Finally the patient was diagnosed with a crisis of pulmonary TB after positive results of a TB polymerase chain reaction examination of the sputum were obtained and from the radiographic findings of the reexamined chest CT scan (Figure 3B). The patient received anti-TB therapy for two months, and he left the hospital in an improved condition.
(B) At two weeks after the initiation of the treatment, a CT scan shows bilateral small parenchymal consolidation with cavitations and small nodules. The crisis of the pulmonary tuberculosis was diagnosed.