emphysematous cystitis is a distinct complicated lower urinary tract infection ( uti ) characterized by air within the bladder wall and lumen . patients with chronic utis , indwelling urethral catheters , urinary tract outlet obstruction , or neurogenic bladders are predisposed to complicated utis such as emphysematous cystitis . air within the urinary tract can also occur due to instrumentation , fistula to a hollow viscus , tissue infarction with necrosis . patients might have varied presentations , ranging from incidental diagnosis on abdominal imaging to severe sepsis . gas - forming infections or emphysematous conditions of the urinary tract are potentially life - threatening , and require prompt evaluation and management . we describe a case of emphysematous cystitis that was managed successfully with bladder drainage , intravenous antibiotics , and strict glycemic control . a 45-year - old male who was a known case of type-2 diabetes mellitus for last 16 years , complained of on and off fever , dysuria and turbid colored urine for last 3 months . he had past history of suprapubic catheterization for obstructive uropathy due to meatal stenosis 15 years back . clinical examination revealed pallor , penile hypospadias , meatal stenosis , bilateral nonproliferative diabetic retinopathy and evidence of sensory neuropathy . investigations showed anemia ( hb7.7 gm / dl ) , neutrophilic leukocytosis ( total leukocyte count 19800 cells / cmm ( n , 400011000 cells / cmm ) with 90% neutrophils . serum creatinine was 3.5 mg / dl ( n , 0.6 - 1.2 mg / dl ) and hba1c was 8.5% ct abdomen revealed intraluminal and intramural gas in the bladder with thickening of bladder wall [ figure 1a  c ] . kidneys were normal in size and shape and there was no perinephric stranding or gas in renal parenchyma or renal pelvis . figure 1d shows disappearance of intramural and intraluminal gas on follow up ct imaging after 8 weeks . serum creatinine was decreased to 2 mg / dl , but not normalized probably because of underlying diabetic nephropathy . ( c ) axial ct image through lower pelvis showing pneumobladder , intramural air and circumferential mural thickening . ( d ) axial ct image through lower pelvis after treatment showing disappearance of air ; however , mural thickening is persisting other organisms reported include klebsiella pneumoniae , pseudomonas aeruginosa , proteus mirabilis , candida albicans , and candida tropicalis , aspergillus fumigatus , staphylococcus aureus , group d streptococcus , enterococcus faecalis , enterobacter aerogenes , and clostridium perfringens and cl . the clinical presentation of emphysematous cystitis is varied ; patients can be asymptomatic , describe pnematuria , or irritative voiding symptoms , or present with an acute abdomen with severe sepsis . of reported patients with emphysematous cystitis , predisposing factors for emphysematous cystitis include diabetes mellitus , neurogenic bladder , lower urinary tract obstruction , urethral catheter placement , vesicourethral reflex , and end stage renal disease . the effects of diabetes mellitus on the urinary tract include diabetic nephropathy , renal papillary necrosis , renal artery stenosis , and bladder dysfunction secondary to neuropathy . these factors combined with glycosuria and impaired leukocyte function place diabetic patients at greater risk of complicated utis such as emphysematous cystitis . overall , two - thirds of reported cases of emphysematous cystitis were diabetic and 64% were women . the symptoms of emphysematous cystitis are similar to those of uncomplicated cystitis , consisting of frequency , urgency , and dysuria . therefore , a high index of suspicion is required for diagnosis especially in patients with risk factors . plain radiographs of the abdomen reveal radiolucency within the lumen of the bladder as a ring of radiolucency outlining the bladder wall . computed tomography of the abdomen is superior to plain radiographs as a diagnostic tool because it clarifies the extent and location of the gas collection as observed in our case . a pathological assessment of involved bladder tissue might show bladder wall thickening with vesicles of varying size , and microscopically there are multiple gas filled vesicles predominantly within the bladder mucosa , lined by flattened fibrocytes and multinucleated giant cells . it is thought that the high glucose concentration within the tissues acts as a favourable substrate for organisms to produce carbon dioxide through facultative anaerobic glycolysis . however , this does not account for the significant number of non - diabetic patients with emphysematous infections . in such patients , urinary albumin might act as the substrate for gas production by urinary pathogens . another theory suggests that an impaired host response , involving vascular compromise and impaired catabolism within the tissues , predisposes patients to gas production within these tissues . the pathogenesis is not yet fully understood , but a multifactorial aetiology of impaired host responses with sugar or protein fermentation seems to be a plausible explanation for the production of gas within the affected tissues . management consists of adequate urinary drainage , appropriate antibiotic treatment , and good blood glucose control . however , delayed diagnosis may lead to extension to the ureters and renal parenchyma , bladder rupture , and death . the gas is reabsorbed once the infection is eliminated as was seen in our patient [ figure 1d ] . history of pneumaturia and evidence of intraluminal and intramural gas along with bladder thickening on imaging clinches the diagnosis of emphysematous cystitis .
emphysematous cystitis is a relatively rare clinical entity caused by gas - fermenting bacteria or fungus . 
 presentation is often nonspecific and imaging is the best diagnostic modality . 
 we report a case of a 45-year - old male who presented with fever , dysuria , and pneumaturia , and was found to have emphysematous cystitis .