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+We describe the case of a 91-year-old woman, type 2 diabetic treated with oral hypoglycaemic agents, hypertensive, and previously dependent for physical activities of daily living after an ischaemic stroke. The family reports that the patient has presented with vomiting, hypogastric pain and haematuria in the last 15 days. Initially treated with fosfomycin-trometamol on an outpatient basis, the condition worsened in the last 48 hours with jaundice and generalised abdominal pain, and the patient was brought to the Emergency Department.
+The patient was conscious, oriented, afebrile and normotensive. Physical examination revealed jaundice and abdominal pain on palpation in the hypogastrium and right hypochondrium, with no evidence of associated peritoneal irritation.
+Biochemistry showed poor glycaemic control (glucose: 571 mg/dL), cholestasis and cytolysis (total bilirubin: 10.9 mg/dL; direct bilirubin: 9.3 mg/dL; GOT: 57 U/L; GPT: 134 U/L; GGT: 806 U/L; alkaline phosphatase: 657 U/L) and acute renal failure (creatinine: 2.8 mg/dL). The haemogram is practically normal (white blood cells: 11,990/mm3 with 75.9% neutrophils; haemoglobin: 15.5 g/dL; platelets: 217,000/mm3). Systematic urinalysis shows glycosuria, microhaematuria and negative nitrites. The urine sediment was clearly pathological, with abundant leukocytes and germs.
+Additional tests included a simple abdominal X-ray, which revealed the presence of ectopic air in the lower pelvis, probably in the bladder wall, suggestive of emphysematous cystitis, and an abdominal ultrasound, which confirmed the presence of gas bordering the bladder wall. In addition, there was evidence of a large dilatation of the gallbladder and the intra- and extrahepatic biliary tract, with suspicion of choledocholithiasis. Urine culture isolated more than 100,000 CFU/ml of Escherichia coli sensitive to amoxicillin-clavulanic acid, cefuroxime-axetil, cefotaxime, piperacillin-tazobactam, gentamicin and trimethoprim-sulfamethoxazole.
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+With a diagnosis of obstructive jaundice and emphysematous cystitis, admission was decided. Intravenous antibiotic treatment was initially started with piperacillin-tazobactam, urinary catheterisation and strict control of blood glucose levels. An abdominal-pelvic CT scan was requested which confirmed the diagnosis of emphysematous cystitis. The obstructive jaundice resolved after retrograde cholangiopancreatography and endoscopic sphincterotomy, and no bile duct stones or bile duct dilatation were found in the control ultrasound.
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+After 5 days of intravenous antibiotic treatment, given the patient's good general condition, it was decided to discharge her from hospital with oral antibiotic treatment with amoxicillin-clavulanic acid for 14 days, maintaining the urinary catheter. The control urine culture after treatment was negative. A follow-up abdominal-pelvic CT scan showed no evidence of residual lesions.
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