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We report a patient in whom lupus peritonitis and cystitis developed after ovulation induction therapy with human menopausal and chorionic gonadotropins followed by in vitro fertilization and embryo transfer. The lupus peritonitis and cystitis presented clinically as an acute abdomen. This disease should not be misdiagnosed as a nonspecific or infectious pelvic peritonitis, especially after oocyte retrieval.
We present the case of a 45-yr-old female patient with a 23 yr history of interstitial cystitis that multiple surgical procedures, including a ceco-cystoplasty, were unable to cure. After a cystectomy was performed, histological examination of the bladder showed the development of collagenous colitis. Although the etiology of both interstitial cystitis and collagenous colitis is unknown, this report postulates an association between these two conditions.
Interstitial cystitis is a disease primarily of young and middle-aged women that is characterized by pelvic pain, urinary frequency, and dyspareunia. Its cause is unknown, but defects in the protective glycosaminoglycan layer of the bladder mucosa may be responsible. The diagnosis is mainly one of exclusion. Cystoscopy reveals characteristic glomerulations in the bladder mucosa. Of the available treatments, the most common are intermittent hydrodilation of the bladder and intermittent intravesical instillation of dimethyl sulfoxide. Other methods and medications are currently under investigation. Although interstitial cystitis is uncommon, its potentially devastating effects may be modified or even averted if primary care physicians are familiar with its presentation and maintain a high index of suspicion.
To identify bacterial predictors of recurrence and/or persistence in acute cystitis, extended virulence genotypes were compared with clonal background and epidemiologic status among 74 Escherichia coli urine isolates from women with first or recurrent episodes of urinary tract infection (UTI). Sequential isolates from patients with recurrent UTI were classified, using macrorestriction analysis, as having caused an isolated recurrence versus a single or multiple same-strain recurrences. papA, papG allele II, iha, and iutA predicted multiple same-strain recurrences, whereas nfaE and the absence of sfaS or fyuA predicted isolated recurrences. Phylogenetic group B2 accounted for 70% of isolates and for most of the putative virulence factors (VFs) studied. The meningitis-associated O18:K1:H7 clonal group comprised 18% of isolates, exhibited multiple VFs, and caused "once-only" recurrences less commonly than did other strains. These findings identify specific VFs and clonal groups against which preventive interventions might be beneficial and illustrate the importance of delineating pathogenetically relevant subgroups within the "recurrent cystitis" population.
BK virus-associated hemorrhagic cystitis is a common clinical problem in bone marrow transplant recipients but is considered rare in other immunosuppressed patient populations. We describe a human immunodeficiency virus-infected patient with non-Hodgkin's lymphoma in whom BK virus-associated hemorrhagic cystitis developed; viruria was quantitated in urine by immunocytochemistry, and the patient showed no response to cidofovir.
The distribution of the three alleles of the P adhesin gene papG (classes I-III) was assessed among 74 Escherichia coli urine isolates from women with first-episode or recurrent cystitis, and papG genotype was compared with clinical origin, O serogroup, agglutination of Gal(alpha1-4)Gal-coated latex beads and human or sheep erythrocytes, and hemolysin production. The class-III-only papG genotype (27% of strains) predominated over the I + III (3%) and II-only (7%) genotypes, irrespective of clinical category. In contrast to the class II papG allele, the class III allele was significantly concentrated in serogroups O6 and O18. Agglutination phenotypes corresponded significantly but incompletely with papG genotype, whereas hemolysin production and papG positivity were tightly correlated. These findings suggest that in acute cystitis in adult women, the class III papG allele predominates, confers distinctive agglutination phenotypes, and is restricted to specific E. coli lineages.
A meta-analysis of six double-blinded clinical trials was undertaken to identify risk factors associated with bacteriologic outcome in 3,108 women with acute cystitis. Eleven antibiotic regimens were used, including ciprofloxacin, ofloxacin, norfloxacin, trimethoprim-sulfamethoxazole, and nitrofurantoin. Entry criteria for all studies were identical. Among 2,409 patients who were defined to be valid for efficacy analysis, pathogens included Escherichia coli (78.6%), Staphylococcus saprophyticus (4.4%), Klebsiella pneumoniae (4.3%), Proteus mirabilis (3.7%), and "other" (9%). Causative bacteria were eradicated at the end of treatment in 93% of patients. The following parameters were associated with successful bacteriologic outcome: not using a diaphragm (P = .0041), treatment for > or = 3 days (P = .0043), pathogen not "other" (P = .0043), symptom duration of < 2 days (P = .0096), and African American race (P = .0147). K. pneumoniae (P = .0496) and "other" pathogens (P = .0018) were associated with increased probability of bacteriologic treatment failure. The presence of pyuria (> or = 10 WBCs per high-power field) did not correlate with outcome and was inversely correlated with the finding of > or = 10(5) bacterial colony-forming units per mL of urine (P < .001). This large database identifies new parameters associated with treatment outcomes of acute cystitis and calls into question current clinical trial guidelines.
Thirteen patients with interstitial cystitis diagnosed by the NIH criteria were treated with intravesical electromotive administration of lidocaine and dexamethasone followed by cystodistention. After a mean follow-up of 10 (range 3-22) months, 8/13 (62%) of the patients reported complete resolution of bladder symptoms lasting an average 4.5 (range 0.75-17) months. Partial or short-term improvement of bladder symptoms was observed in three patients, while two patients reported aggravation of pain for several days after therapy. A significant increase in bladder capacity, to an average 166% of the pretreatment capacity, was observed in all patients. Whenever symptoms recurred after initially effective therapy, retreatments were performed with equal efficacy in 11 patients. This promising new therapeutic approach, performed on an outpatient basis, may become first-line treatment for patients with interstitial cystitis.
A 67-year-old woman who had underlying rheumatoid arthritis and diabetes mellitus had an 8-year history of recurrent hemorrhagic cystitis. During her most recent episode of cystitis, a specimen of urine yielded herpes simplex virus type 2 in culture. A biopsy of the bladder mucosa revealed intranuclear inclusions in multinucleated and mononuclear giant cells that were positive for herpes simplex virus type 2 by immunoperoxidase staining. She had no evidence of infection with herpes simplex virus outside her bladder.
The efficacy of a single dose (four tablets) and of 10-day courses of trimethoprim-sulfamethoxazole (TMP-SMZ) was studied in 77 women with symptomatic cystitis and negative tests for antibody-coated bacteria. Cure rates after six weeks were 76% for single-dose therapy and 87% for 10 days of treatment. For Escherichia coli infections, cure rates after six weeks were 80% and 86%, respectively. However, 10-day treatment eliminated enteric bacilli from urethral and vaginal sites more often than did single-dose therapy. Two weeks after completion of treatment, perineal colonization was observed more often in the women who developed recurrent infections than in those who did not (P = 0.01). During these two weeks, recurrent infections were found somewhat more often in the women who had received single-dose therapy than in those who had undergone 10-day treatment (5 of 38 vs. 2 of 39; P = 0.07). With conventional courses of antibiotics, retreatment of all recurrent infections was less successful in women previously given single-dose therapy. Recurrent infections were also more frequent in women infected with bacteria other than E. coli. Both drug regimens were well tolerated. However, serious adverse reactions were fewer in patients treated with a single dose (8.5%) than in patients treated for 10 days (15%). Single-dose therapy with TMP-SMZ appears as effective as 10-day therapy in acute uncomplicated cystitis caused by E. coli.
Two years after a microbiological study of the urethral syndrome 32 sufferers and 26 controls were asked what they felt caused 'cystitis' symptoms, what they did to prevent recurrences and how they managed acute episodes. Doctors may feel that they have discharged their clinical responsibility by excluding pathogens but the patient is often confused and frustrated by the mismatch between her own ideas on causation and the paradoxical ideas of her doctor. The findings indicated that both patient groups think in a divergent and largely non-biomedical manner about their symptoms. Medical advisers were unlikely to explore lay ideas on cystitis or reinforce self-help measures. Clinicians would be well advised to take lay ideas into account and, where appropriate, to capitalize on them in negotiating management.
Urine specimens from 65 adult patients with symptomatic urinary tract infections that involved 91 episodes of well-defined acute pyelonephritis or cystitis were tested for antibody-coated bacteria (ACB) by a fluorescent antibody assay, unbound bacteria-specific antibody by radioimmunoassay (RIA), and levels of total protein and IgG. Acute pyelonephritis was associated with positive tests for ACB (22 [69%] of 32), elevated levels of unbound antibody (28 [88%] of 32), and a mean RIA binding ratio of 9.4. Cystitis was associated with negative tests for ACB (56 [95%] of 59), low levels of antibody in urine (38 [64%] of 59), and a mean RIA binding ratio of 3.2. The results showed that a negative test for ACB may occur with elevated levels of unbound antibody in the urine because, although elevated, levels were still too low to result in detectable antibody coating of the bacteria. There was often, but not always, a correlation between RIA binding ratios and levels of urinary protein and IgG.
The prevalence of virulence factors possessed by Escherichia coli colonizing the periurethra was examined and compared with that of E. coli causing urinary tract infection. One hundred two E. coli isolates obtained from the periurethra and urine of 7 non-sexually active girls at risk for cystitis were characterized for genetic relatedness and examined for expression of six virulence factors. Expression of virulence factors in colonizing clones of E. coli were compared with expression in clones from symptomatic infection. All virulence factors except P adhesin were commonly expressed by colonizing clones of E. coli that did not go on to infect the urinary tract. Although P adhesin-expressing E. coli were commonly isolated from episodes of cystitis, the presence of P adhesin on periurethral E. coli did not usually predict subsequent infection. By itself, expression of virulence factors on periurethral E. coli is not enough to predict subsequent infection.
In a double-blind multicentre study the efficacy and safety of a single-dose treatment with pefloxacin (800 mg) was compared with a five-day treatment regimen of 960 mg co-trimoxazole twice daily in the therapy of acute uncomplicated cystitis in women. In order to maintain blindness, patients in the pefloxacin group received placebo to complement the full number of tablets. Nine centres were involved; 155 patients received pefloxacin and 161 patients received co-trimoxazole. Of these, 140 patients treated with pefloxacin and 145 with co-trimoxazole were considered valid for efficacy and safety analysis. At the first follow-up, after seven to ten days, 97.1% of the pefloxacin group and 95.2% of the co-trimoxazole group were bacteriologically cured. At the second follow-up visit, after 28 to 42 days, the urine culture was negative in 95.0% of the pefloxacin group and 90.3% of the co-trimoxazole group. A single dose of 800 mg pefloxacin was demonstrated to be as safe and at least as effective as a five-day regimen of co-trimoxazole in the treatment of uncomplicated cystitis.
Pivmecillinam was compared with cotrimoxazole in the treatment of uncomplicated bacterial cystitis in general practice. Similar bacteriological cure rates were obtained with the two treatments. Although micrococci were judged resistant to pivmecillinam by the disc sensitivity method used, cystitis attributed to these organisms and to resistant strains of Proteus mirabilis responded as readily as those due to apparently sensitive Gram-negative bacteria. Pivmecillinam was well tolerated.
High-dose ifosfamide (one or two courses of 6 g/m2) with or without mesna was administered to 13 patients with advanced non-small cell lung cancer. The protective effect of 2-mercapto-ethane sulfonate (mesna) against the urotoxic side effects induced by ifosfamide was examined by a randomized crossover trial. A significant reduction in the incidence of hematuria was observed in the patients receiving mesna. Macroscopic hematuria was observed in only one patient who received treatment with mesna versus seven patients treated with ifosfamide alone. Other symptoms, such as frequency and dysuria, tended to be diminished in the patients receiving mesna, although the difference was not statistically significant. Our results suggest that mesna is effective in preventing or diminishing ifosfamide-induced hemorrhagic cystitis. Concomitant use of mesna should allow the administration of a high dose of ifosfamide although more extensive studies are needed to define the optimal dose and schedule of administration of mesna to prevent or attenuate the hemorrhagic cystitis.
A case is reported in which temozolomide, a promising new DNA alkylating agent, was successfully used to treat radiation refractory metastatic brain tumors arising from primary breast cancer. However, the treatment had to be terminated after the second round of treatment due to the development of hemorrhagic cystitis. This side effect was totally unexpected. Another class of alkylating agents (cyclophosphamide and related compounds) exhibits this side effect caused by a prevalent acrolein metabolite. Temozolomide and its sister compounds, dacarbazine and 5-(3-methyltriazen-1-yl)imidazole-4-caroxamide, have never been reported to have this adverse reaction. This case serves to alert physicians to the existence of a possible subpopulation of patients who may experience hemorrhagic cystitis on treatment with imidazotetrazines by a mechanism that is yet to be established.
Several studies have reported histologic findings in interstitial cystitis (IC) bladder biopsy specimens. However, these studies used a variety of criteria to define IC, which may explain the variation noted in the histologic changes. Clinical experience shows that these biopsy specimens are often not helpful in confirming the diagnosis. Our study was designed to examine the histologic features identified in bladder biopsy specimens from patients with IC and compare them with biopsy specimens from a control population. Although IC patients as a group had a higher incidence and degree of denuded epithelium, ulceration, and submucosal inflammation, none of these findings was pathognomonic. In addition, these findings occurred only in interstitial cystitis patients with pyuria or small bladder capacity. The inflammatory infiltrate seen in IC was composed predominantly of lymphocytes, with increasing numbers of plasma cells as the degree of inflammation increased. There was no specific predilection for the inflammatory infiltrate to be perineural. Submucosal inflammation was associated with denuded epithelium, ulceration, pyuria, and a clinical response to therapy suggesting a pathophysiologic relationship. Epithelial and basement membrane thickness, submucosal edema, vascular ectasia, fibrosis, and detrusor muscle inflammation and fibrosis were not significantly different in the IC and control patients. These findings suggest that IC is a chronic submucosal inflammatory disease, at least in those patients with small bladder capacities or pyuria. IC is best diagnosed from its clinical features; the histologic changes identified in the bladder biopsy play a supportive role in this diagnosis. Mast cells play a limited role in the diagnosis of IC.