A 62-year-old man with a past history of chronic obstructive pulmonary disease and recent ischemic cerebral stroke was referred to the department of Urology for an acute urosepsis. The patient was suffering from recurrent cystitis and a spontaneous rupture of the right upper urinary tract treated by antibiotics only (Ciprofloxacin).
On admission, the patient presented fever, pelvic pain, dysuria and urinary retention which was treated by a transurethral catheter.
On examination, the patient was febrile (39 c) with tachycardia and low blood pressure (90/50 mmHg). Digital rectal exam was painful and abdominal examination was normal.
Blood analysis showed a neutrophilic leukocytosis and a high C-reactive protein level (256 mg/L).
Urinalysis revealed alkaline urine (ph = 7,6) with pyuria and hematuria.
The diagnosis of an urosepsis caused by urinary infection was highly suspected.
The patient was hospitalized, probabilistic antibiotherapy based on ofloxocin and ceftriaxone was prescribed until urinary culture results are ready.
A CT scan was performed and showed a calcified thickening of the whole bladder (Fig. 1), a moderate hydro-nephrosis in the right side with a small calcification on the right renal pelvis. (Fig. 2).
After 24 h, the patient was afebrile, without tachycardia and blood pressure was normal.
Regarding this radiological aspect of the bladder, a cystoscopy was performed seven days later and showed a calcified, hyperemic and fragile bladder with a thickened wall involving the whole bladder (Fig. 3).
Multiple biopsies during endoscopy were performed.
Many diagnoses were suspected such as muscle invasive tumor, urinary tract bilharziasis, tuberculosis and encrusted cystis.
Biopsies were sent for pathological and parasitological analysis.
In addition, a non-specific and specific bacteriological culture for Corynebacterium and tuberculosis were carried out.
Bacterial culture results were positive to CBGD2.
The diagnosis of encrusted cystitis and pyelitis was highly considered.
An adapted antibiotherapy was undertaken using vancomycin 15 mg/kg every 8 h during 3 weeks.
Four days later, the patient presented an acute peritonitis with acute abdominal pain and abdominal tenderness.
A laparotomy was performed urgently. An unusual Bladder rupture in the dome, far from biopsy location, was found. Surgical repair was realized.
On pathological examination, the photomicrograph showed an extensive bladder mucosal ulceration with necrosis and microcalcifications and increased vascularity of the lamina propria (Hematoxylin and Eosin (HE) x40) (Fig. 4A). A high power view showing microcalcifications and necrotic debris surrounded by an inflammatory cellular infiltrates of lymphocytes, eosinophils, histiocytes and foreign body giant cells (HE x400) (Fig. 4B).
The diagnosis of encrusted cystitis was confirmed by histological findings.
A cystectomy was discussed but we opted for a conservative treatment based on literature finding.
The diagnosis of encrusted cystis was confirmed by anatomo-pathological exam.
Seven days later, a second laparotomy was performed because of an acute peritonitis due to complete bladder rupture. The Bladder reparation was not possible and a complete cysto-prostatectomy and bilateral ureterostomy were performed.
The post operative outcomes were uneventful. Vancomycin was carried on during 3 weeks. Bacterial urinalysis was negative.
Control CT-scan showed pyelic calcification regression and the patient was discharged home.