Journal of Diabetology, October 2012; 3:5 http://www.journalofdiabetology.org/ Case Report: Emphysematous prostatitis in a patient with diabetes C . A. S oh oni Abstract Emphysematous prostatitis is a rare condition that is characterized by gas and pus accumulation in the prostate. We report a 70 year old man with emphysematous prostatitis caused by Escherichia coli (E.coli). He had a history of long standing diabetes mellitus. He was admitted with fever and dysuria. Computed tomography (CT) scans corroborated the existence of air collection in the prostate. Under the impression of emphysematous prostatitis, the patient was successfully treated with antibiotics without the need for any major surgical intervention. Key words: Emphysematous prostatitis, diabetes mellitus, computed tomography *Corresponding author: artery (LAD) stenosis. There were no other underlying co-morbid conditions. (Current Details) Chandrashekhar A. Sohoni Department of Radiology, B-5, Common Wealth Hsg. Soc., Opp. Bund Garden, Pune, Maharashtra, India. E-mail: [email protected] [email protected] Introduction Emphysematous infections of urinary tract are commonly encountered in patients with diabetes. However, emphysematous prostatitis due to E.coli is a very rare entity with only one case being previously described in the literature [1-3]. The case reported here reveals the importance of early diagnosis of this condition using CT scan and effective management with parenteral antibiotics. Case presentation A 70 year old normotensive male patient came with the complaints of fever with chills, malaise, and difficulty in passing urine and lower abdominal pain since the last five days. He was a patient with diabetes for the past 17 years, treated with twice daily pre-mixed insulin and metformin. His laboratory reports of the past two years showed satisfactory glycemic control with last three glycated hemoglobin (HbA1c) values of < 7 %. The patient was a known case of coronary artery disease and angioplasty had been performed two years ago for 90% left anterior descending coronary (Page number not for citation purposes) Page 1 On physical examination, blood pressure was 90/60 mmHg, pulse rate 110 beats/min, and body temperature was 1010F. He looked acutely ill and abdominal examination revealed suprapubic tenderness. Digital rectal examination revealed moderate enlargement of prostate with a benign feel. Laboratory examination was significant for random blood glucose of 385 mg/dl, total leucocyte count 23,000/ mm3 and serum creatinine was 1.3 mg/dl. Many red blood cells and white blood cells were seen on high power field microscopic examination. Ultrasound examination revealed thickening of urinary bladder wall with presence of air within the bladder. The prostate could not be optimally visualized and there was significant post-void residual urine. Due to persistence of lower abdominal pain CT scan was performed, which revealed air replacing the prostatic parenchyma and seminal vesicles, suggesting a diagnosis of emphysematous prostatitis (Figures 1, 2 & 3). Air was also noted within the urinary bladder and perivesicle space (Figure 2 & 3). E. coli was isolated from the culture of urine. The patient was empirically administered intravenous antibiotics (ceftriaxone, metronidazole and levofloxacin) before the availability of culture report. Ultrasound guided trans-rectal aspiration of prostate revealed only a minimal aspirate, which was also cultured and grew E.coli. Based on sensitivity report, Journal of Diabetology, October 2012; 3:5 http://www.journalofdiabetology.org/ intravenous antibiotics ceftriaxone and levofloxacin were continued for two weeks, followed by oral levofloxacin for the next four weeks. Repeat CT scan performed on day 14 of admission revealed mild regression of the infective process. Foley’s catheter was removed on day 23 of admission. The patient had significantly improved clinically and the total leucocyte count had reduced to 11,000/ mm3 at the time of discharge on day 26. Figure 3 Caption (legend) for images Contrast enhanced CT scan images (Figures 1, 2 & 3) reveal gas replacing the prostate parenchyma. Presence of gas is also noted within the urinary bladder and in the perivesicle space (Figures 2 & 3). Discussion Emphysematous prostatitis is a rare entity. Patients with diabetes are predisposed to urinary tract infections. Infections by gas forming organisms like E. coli, Klebsiella, Proteus and Citrobacter species occur with increased frequency in patients with diabetes [2,4,5]. However, cases of emphysematous prostatitis caused by E. coli are extremely rare. Only one such case has been reported previously [3]. Figure 1 Bacteria such as E. coli are facultative anaerobes which can ferment glucose and fructose to produce carbon dioxide and hydrogen. The gas formed due to this necrotizing infective process replaces the normal parenchyma. The signs and symptoms of emphysematous prostatitis are non-specific [6]. Digital rectal examination can reveal an enlarged prostate, however, there are no specific findings suggesting emphysematous infection. Radiography is usually the initial imaging modality used in patients with abdominal pain. Radiography may be helpful in suggesting the Figure 2 (Page number not for citation purposes) Page 2 Journal of Diabetology, October 2012; 3:5 diagnosis of emphysematous prostatitis if gas is visualized in the region of prostate. In our case, this finding was missed on the radiograph, as the gas shadow was mistaken for rectal gas. Ultrasonography is usually accurate in revealing the diagnosis [7]. However, the presence of gas may make visualization of prostate difficult, as in our patient. Trans-rectal sonography is more accurate than transabdominal sonography in making the diagnosis of emphysematous prostatitis. In our case, trans-rectal sonography was performed for guided aspiration only after the CT scan, since the diagnosis was not suspected at the time of transabdominal sonography. Ultrasound guided trans-rectal aspiration of prostate can also help in diagnosis and treatment. CT scan is the most sensitive and specific modality to make a diagnosis and should be performed in suspected cases [3,6,8,]. Conclusion Mortality due to emphysematous prostatitis is significant (25%) and hence early diagnosis and aggressive treatment is imperative [10]. In our case, the early diagnosis was made on CT scan which was performed due to the persistent symptom of lower abdominal pain. The diagnosis was initially missed on radiography and sonography in this case; however, in retrospect the indicative findings could be seen. 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