Introduction:
Emphysematous cystitis is a rare and potentially serious complication of urinary tract infections (UTIs), characterized by the presence of gas within the bladder wall and lumen, caused by bacterial fermentation of glucose under anaerobic conditions. It is more frequently observed in patients with diabetes, especially those with poor metabolic control, which predisposes them to both UTIs and complications.
iSGLT-2 inhibitors, such as empagliflozin, have been widely used due to their favorable impact on glycemic control, cardiovascular outcomes, and renal protection. These agents promote glucose excretion through the urine (glucosuria), reducing blood sugar levels and offering additional benefits in terms of weight loss and blood pressure reduction. However, their glucosuric action also creates a favorable environment for infections. Genital fungal infections are a known and relatively common side effect, affecting 5-15% of patients. Bacterial UTIs, though less frequent, have been reported in 4-9% of cases. Emphysematous cystitis, in particular, is an exceptionally rare complication, with only two cases previously documented in association with iSGLT-2 use.
Methods:
This is a description of a clinical case. The patient has provided written consent for the publication of this material.
Results:
An 83-year-old woman with a 20-year history of type 2 diabetes mellitus, treated with metformin and linagliptin, was started on empagliflozin and insulin due to poor glycemic control (HbA1c 10%). She used this regimen for 4 weeks before presenting with 3 days of altered mental status, gait instability, pelvic pain, and urinary incontinence.
On examination, she was afebrile, hypertensive, and eucardic, with pelvic pain rated at 5/10 on the VAS, without signs of peritoneal irritation. Laboratory findings revealed: leukocytes 15,210 cells/mm³, plasma sodium 113 mEq/L, potassium 3.7 mEq/L, chloride 80 mEq/L, creatinine 0.57 mg/dL, glucose 212 mg/dL, CRP 192 mg/L. Urinalysis showed proteins 30 mg/dL, glucose 500 mg/dL, positive nitrites, negative ketones, leukocytes 25-50 per field, red blood cells 5-10 per field, with abundant bacteria and yeasts.
The patient was admitted with a diagnosis of severe hyponatremia and sepsis. She was started on antibiotics and hypertonic saline for a gradual correction of plasma sodium and improvement of her neurological symptoms.
A PyeloCT scan revealed emphysema of the bladder wall, suggestive of emphysematous cystitis (Figure 1). Urine culture was positive for Escherichia coli. She completed treatment with third-generation cephalosporins and urinary catheterization, resulting in a favorable clinical response.
Conclusions:
This case highlights the importance of closely monitoring for rare complications like emphysematous cystitis in patients on iSGLT-2 inhibitors, particularly those with long-standing diabetes and poor control. While the cistitis could be linked to poor metabolic control, the timing of empagliflozin use strongly suggests the drug as a contributing factor. Although large trials have not demonstrated a significant association with complicated UTIs, the glucosuric effect of iSGLT-2 inhibitors may create conditions favorable for emphysematous cystitis. The rarity of this complication emphasizes the need for further research and increased clinical awareness as these drugs become more widely used
I have no potential conflict of interest to disclose.
I did not use generative AI and AI-assisted technologies in the writing process.