|Year : 2014 | Volume
| Issue : 2 | Page : 117-120
Eosinophilic cystitis: Report of two cases and review of literature
Vijaya G Bhaskar, Surya P Vaddi, Chandramohan Godala, Vijay K Vasanthu
Department of Urology, Narayana Medical College, Chintareddypalem, Nellore, Andhra Pradesh, India
|Date of Web Publication||16-Oct-2014|
Department of Urology, Narayana Medical College, Chintareddypalem, Nellore, Andhra Pradesh
Source of Support: None, Conflict of Interest: None
Eosinophilic cystitis is a rare but distinct entity in patients presenting with bladder symptoms. We describe two cases of eosinophilic cystitis in whom no specific cause could be found with review of the literature. In one patient, the symptoms and radiological evaluation suggested a bladder tumour. However, transurethral resection of bladder lesion was done and histology revealed eosinophilic cystitis. The other patient presented with lower urinary tract symptoms of long duration and bladder biopsy revealed eosinophilic cystitis. Both patients were managed conservatively with anti-histamines and steroids and they improved well. The evaluation of the patient with eosinophylic cystitis should include cystoscopy and biopsy to establish histological diagnosis. After diagnosis the patients can be safely and successfully treated conservatively although recurrence is not uncommon.
Keywords: Bladder biopsy, bladder tumor, eosinophilic cystitis, lower urinary tract symptoms
|How to cite this article:|
Bhaskar VG, Vaddi SP, Godala C, Vasanthu VK. Eosinophilic cystitis: Report of two cases and review of literature
. Arch Int Surg 2014;4:117-20
| Introduction|| |
Eosinophilic cystitis is a rare inflammatory lesion of the bladder of unknown origin. Brown and Palubinskas first reported the disease in 1960. , Until now, only around 200 cases have been reported in the literature.  Frequently the disease mimics bladder cancer in clinical, radiographic, and cystoscopic features. The definitive diagnosis can be made only by histopathological examination of biopsy specimens. We present two cases of eosinophilic cystitis; one mimicking bladder cancer and the other presenting with recurrent lower urinary tract symptoms (LUTS).
| Case Reports|| |
A 60-year-old female presented with clot retention of the urinary bladder. She had preceding history of frequency, urgency, dribbling of urine, abdominal pain with episodes of hematuria for 1 year. Systemic examination did not reveal any abnormality. Ultrasound revealed thickened bladder wall with hyperechoic lesion arising from the right lateral wall and bilateral hydroureteronephrosis. Abdominal computed tomography revealed circumferential thickening of the bladder wall with bilateral hydroureteronephrosis [Figure 1]. Urine cytology was negative on three consecutive samples. Cystoscopy revealed focal thickening with a sessile lesion in the right lateral wall of the bladder. Transurethral resection of the lesion was done. Histopathology revealed transitional lining epithelium and subepithelial fibrocollagenous tissue showing chronic inflammatory cells predominantly eosinophils [Figure 2]a and [Figure 2]b.
|Figure 1: Axial section of computed tomography showing thickened bladder wall in Case 1|
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A 55-year-old male, diabetic and hypertensive, presented with fever, pyuria, storage and voiding lower urinary tract symptoms (LUTS) for 1 year. Systemic examination was normal. Ultrasound revealed right focal pyelonephritis with bilateral renal parenchymal changes. Repeated urine cultures were negative. Urine polymerase chain reaction for mycobacterial DNA and cytology for malignant cells was negative. Cystoscopy revealed erythematous patches, but no exophytic growth [Figure 3]. Bladder biopsy revealed fibrocollagenous tissue with predominant eosinophillic infiltrates, few macrophages and lymphocytes [Figure 4].
|Figure 3: Cystoscopic view of diffuse erythematous lesions in the bladder in Case 2|
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|Figure 4: Histopathology of bladder biopsy in Case 2 showing fibrocollagenous tissue with eosinophills and few macrophages (H and E, ×400)|
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Both patients commenced therapy with anti-histamines (cetrizine 10 mg/day) and corticosteroids (prednisolone 20 mg/day) for 4 weeks, and they recovered well.
| Discussion|| |
Eosinophilic cystitis is a rare condition characterized histologically by eosinophilic infiltration of the submucosa and muscular layer. The acute phase presents with tissue eosinophilia, mucosal edema, hyperemia and muscle necrosis. In the chronic phase eosinophilia is not conspicuous and scarring may be prominent.  This disorder can eventually progress to a complete fibrosis of the urinary bladder with secondary involvement of the rest of the urinary tract, resulting in obstructive nephropathy with variable degrees of renal insufficiency. 
According to van der Ouden,  the most common presenting symptoms are urinary frequency (67%), dysuria (62%), gross or microscopic hematuria (68%), suprapubic pain (49%), and urinary retention (10%). First patient in our study presented with hematuria with clots along with frequency and urgency, whereas the second had both storage and voiding LUTS with pyuria and fever. The etiology of eosinophilic cystitis remains unknown, but it is believed to be associated with injury; drugs including methicillin, warfarin, anthranilic acid, intravesical mitomycin, and thiotepa; bacterial, viral, and parasitic infections; and reactions to food and other allergens.  Pathogenesis of eosinophilic cystitis still remains unclear but allergic reactions have been suggested to be more commonly predisposing factors. It could possibly be caused by antigen-antibody reaction leading to production of various immunoglobulins, which in turn cause activation of eosinophils that initiates inflammatory process.  We could not identify any such cause of the disease in our patients. Urine analysis of 77% of patients showed hematuria or pyuria. The ratio of positive urine culture was only 20.5%.  In eosinophilic cystitis, peripheral blood eosinophilia can be found in 43% of cases and up to 50% of patients will have a history of allergy.  Urine cultures in our patients were negative, and peripheral eosinophilia and history of allergy were not present. It usually has a chronic course with periodic recurrences.
Cystoscopy findings may vary considerably with edema, erythema, raised velvety, polypoid, ulcerating to papillary lesions and frankly fungating masses in bladder mucosa. Sometimes an infiltrative mass-like lesion may also be visualized.  In our first case cystoscopy showed sessile lesion mimicking bladder tumor in right lateral wall and the second case had erythematous patches all over the bladder. Eosinophilic lesions may present as a diffuse eosinophilic inflammation of the bladder wall without a mass or as a nodular or sessile lesion. Radiographic findings may show variable thickening of the bladder wall, ranging from diffuse or asymmetrical and irregular thickening to mass formation. The pseudotumorous form of eosinophilic cystitis is characterized by extensive infiltration of the bladder wall that may resemble an invasive tumor. In our first case, there was circumferential thickening of bladder with bilateral hydroureteronephrosis and the second case showed features of pyelonephritis. The radiological features are so varied and give no clue to diagnosis.
Diagnosis can only be made by histological examination of a biopsy specimen of the bladder. It is imperative to obtain adequate deep biopsies; otherwise, the diagnosis can be missed. Histologically, the submucosa is edematous, containing a mixed inflammatory infiltrate in which eosinophils are prominent. The hallmark for diagnosis was diffuse infiltration of eosinophils. which was present in both of our cases.
Although treatment for eosinophilic cystitis has not yet been standardized, it mainly involves removal of the allergen or discontinuation of the drug when an allergy is the clear cause. Most of them respond to anti-histamines and nonsteroidal anti-inflammatory drugs. In refractory cases corticosteroids should be added.  Our patients responded well to such treatment. The success rate of this therapy reaches 80-100% when on corticosteroids.  Transurethral resection of the disorder lesion, immunosuppressive agents, such as cyclosporine can be considered. Around 7% of cases show an aggressive course with recurrent hematuria, impaired renal function and resistance to medical treatment.  Only in patients who have a disease intractable to conservative treatments and presenting as profuse hematuria, contracted bladder, distal ureteral involvement partial or total cystectomy, and urinary diversion must be considered. 
| Conclusion|| |
Eosinophilic cystitis can mimick bladder tumor, carcinoma in situ, genitourinary tuberculosis, interstitial cystitis. High index of suspicion is required to diagnose eosinophilic cystitis. Only histopathology provides the diagnosis and most of the times it can be managed conservatively with nonsteroidal anti-inflammatory drugs, anti-histamines and steroids. Occasionally, it may lead to serious bladder disease with upper tract deterioration and create a urologic cripple.
| References|| |
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]