as environmental and personal sanitation improves , the incidence of typhoidal salmonellosis tends to decrease , while the incidence of non - typhoidal salmonellosis markedly increases , . the most common clinical manifestation of nts is gastroenteritis , and the condition includes bacteremia , focal infection , and an asymptomatic carrier state . of the manifestations , urinary tract infection ( uti ) is unusual and rare , , and occurs in immunocompromised individuals , including patients with a malignancy , human immunodeficiency virus infection , or diabetes mellitus and patients receiving corticosteroid therapy or treatment with other immunotherapeutic agents , . uti caused by nts presents as either pyelonephritis or cystitis , , ; cases of hemorrhagic cystitis are extremely rare . we report a case of severe hemorrhagic cystitis caused by nts that resulted in shock and syncope in a patient with uncontrolled diabetes . a 41-year - old man came to the emergency room for a fever that had developed 10 days earlier , and was accompanied by pus - like urine . the patient had watery diarrhea and had lost five kilograms of weight in one month . he had been diagnosed with diabetes mellitus 5 years earlier and his blood sugar level was not well controlled . the patient was a baker , did not have any pets , and did not have a history of recent travel . on admission , his temperature was 38  c , his blood pressure was 110/60  mm hg , and his heart rate was 102 beats / min . platelets were 209,000/mm , hemoglobin was 13.6  g / dl , hematocrit was 40.9% , bun / creatinine was 34.0/1.0  mg / dl , fasting / postprandial two - hour blood sugar was 330/482  mg / dl , and hba1c was 11.1% . a widal test showed a typhoid o titer of 1:1280 and typhoid h titer of 1:640 , and a urine culture grew nts ( group d ) . no bacteria were isolated from the stool or blood culture . on abdomen - pelvis ultrasonography , the urinary bladder was filled with pus , the bladder wall was thickened diffusely ( fig . 1a ) , and hydronephrosis and hydroureter were observed on both sides of the bladder ( fig . the level of serum creatinine and urine output remained a consistent level during this period . after 10 days in the hospital , the patient 's urine output decreased suddenly and he developed severe lower abdominal distension and syncope . the patient 's systolic blood pressure fell to 80  mm hg and hemoglobin to 7.9  g / dl . an emergency ct scan showed that the urinary bladder was severely distended and filled with a mass suspicious of hematoma ( fig . 3 ) . however , there was no stone , mass or focal mechanical injury , i.e foley catheter injury . blood pressure was stabilized after transfusion of three packs of rbc and hemoglobin was elevated to 10.2  g / dl . he responded well to treatment and was discharged in good condition with oral antibiotics and oral hypoglycemic agents . despite improvements in individual and collective sanitation as well as the careful monitoring of food processing , sporadic episodes and outbreaks of salmonellosis continue to occur in industrialized countries . the overall incidence of typhoidal salmonellosis has decreased , whereas that of non - typhoidal salmonellosis has increased , . non - typhoidal salmonellosis is a disease of great public health importance . unlike s. typhi and s. paratyphi , the main mode of transmission is from food products contaminated with animal products or waste , most commonly eggs and poultry , but also undercooked meat , unpasteurized dairy products , seafood , and fresh produce . nts is an enteroinvasive bacterium and causes infections that may have one of four different clinical presentations . however , invasion beyond the gastrointestinal tract occurs in approximately 5% of patients with nts gastroenteritis , resulting in bacteremia . extraintestinal manifestations , which have a rare incidence of about 28% , include endocarditis , pericarditis , arteritis , soft tissue infection , uti and pneumonia . the gastrointestinal carrier state is the fourth clinical presentation and is defined as the excretion of nts for months or years after the initial onset of disease . uti caused by nts is so rare that it comprises only 0.01%3% of positive urinary cultures , ,   and 3% of nts infections . nts has been postulated to enter the urinary tract either hematogenously or by direct invasion of fecal flora to the bladder via the urethra . the risk factors of uti caused by nts include old age , chronic illness , immunosuppressive therapy and structural abnormality of the urinary tract . uti related to nts presents as cystitis , pyelonephritis , renal abscess , or asymptomatic pyuria , . a retrospective analysis of 28 cases of bacteriuria due to nts showed that twenty - one patient ( 75% ) had symptoms of uti ( 16 , cystitis ; 3 , pyelonephritis ; and 2 , renal abscess ) . another review of nineteen patients with bacteriuria due to nts showed that the frequency of uti due to nts was 0.07% ( proportion of positive urine cultures ) . eighteen patients ( 94.7% ) had symptoms of uti ( 12 , cystitis ; 6 , pyelonephritis ) , and 1 remained asymptomatic . however , case of hemorrhagic cystitis due to nts was very rare . furthermore , severe hemorrhagic cystitis caused by nts with massive bleeding that resulted in shock and syncope was extremely rare . uti from salmonella does not differ clinically from uti caused by other members of the enterobacteriaceae 
 . our patient had uncontrolled diabetes for 5 years and had worked at a job in food handling for a long time . we are not sure of the mode of transmission in our patient 's case ; however , we propose that he might have been a salmonella carrier or that his illness was caused by bacteremia from a previous gastrointestinal infection . in uncomplicated salmonella gastroenteritis , antibiotic therapy is not recommended because it does not shorten the disease duration . however , in cases of sepsis or local extraintestinal infection , prompt antibiotic administration is needed . traditionally , antibiotics such as ampicillin , amoxicillin , chloramphenicol , and trimethoprim - sulfamethoxazole are used , but currently the frequency of antimicrobial resistance in salmonella isolates is increasing , . in korea , according to recent reports , group b salmonella is the most common drug - resistant serotype , while the group d serotype has relatively low drug resistance . the treatment of focal extraintestinal salmonella infection often requires both surgical drainage and antibiotic therapy in cases associated with structural abnormality of the urinary tract . early surgical intervention might be combined with more prolonged therapy to eradicate uti caused by nts , . in this report , we describe a case of hemorrhagic cystitis due to nts , which caused massive bleeding , shock , and syncope in a patient with uncontrolled diabetes .
hemorrhagic cystitis is defined by lower urinary tract symptoms that include dysuria , hematuria , and hemorrhage and is caused by viral or bacterial infection or chemotherapeutic agents . 
 reports of hemorrhagic cystitis caused by non - typhoidal salmonella ( nts ) are extremely rare.we report a case of a 41-year - old man with hemorrhagic cystitis from nts that caused massive bleeding and shock . 
 the patient was hospitalized for uncontrolled diabetes and obstructive uropathy related to severe cystitis . 
 a urine culture was positive for group d nts . 
 this case demonstrated that hemorrhagic cystitis in a patient with a risk factor such as diabetes can be a manifestation of local extra - intestinal nts infection .