Emphysematous prostatitis in a patient with diabetes Case Report:

Journal of Diabetology, October 2012; 3:5
Case Report:
Emphysematous prostatitis in a patient with diabetes
C . A. S oh oni
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]
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
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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
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
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
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).
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
Radiography is usually the initial imaging
modality used in patients with abdominal pain.
Radiography may be helpful in suggesting the
Figure 2
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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
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. We were able to successfully manage the
patient with early initiation of intravenous
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