Clinical Images

When Dysuria Won’t Resolve: A Dangerous Mimic of Urinary Tract Infection

A 64 year-old male with a history of type 2 diabetes mellitus and benign prostatic hyperplasia (BPH) presented to clinic with fevers, dysuria, hematuria, and increased urinary frequency.   Urinalysis showed 3+ leukocyte esterase, and cultures eventually grew E. coli.  The patient was diagnosed with a urinary tract infection (UTI) and prescribed a 7-day course of ciprofloxacin. One week later, the patient returned to clinic with persistent symptoms.  At that visit he was felt to have a complicated UTI, and was prescribed an additional 7 days of ciprofloxacin. After completing fourteen days of antibiotics, the patient returned to clinic reporting no improvement in symptoms.

On exam, he was afebrile but tachycardic, with a heart rate of 130.  There was no penile rash or urethral discharge.  A digital rectal exam revealed no prostatic masses or tenderness.   The patient’s white blood cell count was slightly elevated at 9.7.  Repeat urinalysis was positive for bacteria, trace leukocyte esterase, 11-25 red blood cells, and 26-50 white blood cells.  His EKG showed sinus tachycardia with a heart rate of 131.  He was admitted for further workup of his sepsis. 

On admission, the patient was started on empiric IV antibiotic therapy.  His symptoms did not improve with this, and he began registering objective fevers.  The inpatient medical team obtained a CT abdomen and pelvis for further evaluation, which revealed two large prostate abscesses (Figure 1.  The patient was taken to the operating room, where the abscesses were drained, and ceftriaxone was injected into the prostatic tissue.  Cultures taken from the abscess fluid would eventually grow out E. coli and Enterococcus faecalis.  After a few more days of IV antibiotics, he was able to be discharged to complete a 4 week course of linezolid (E. faecalis was resistant to ciprofloxacin).  The patient was symptom free at his one-month follow-up visit. 

Figure 1. CT of the Abdomen and Pelvis shows a diffusely enlarged heterogeneous prostate, with 2 large fluid collections.  The fluid collection on the left measures 4.6 cm x 3 cm, and the collection on the right measures 2.1 x 1.3 cm.

Acknowledgments: Presented as a poster at the national Society for General Internal Medicine meeting in Denver, CO 2013.
Conflict of Interest: None

AUTHOR BIOS:

Joseph Knapper is a resident in the Department of Medicine at Emory University in Atlanta, Georgia.  He was born in Minnesota and attended medical school at the University of Minnesota.

Nisha Fernandes is a resident in the Department of Psychiatry at Emory University in Atlanta, Georgia.  She was born in Bangalore, India and attended medical school at the University of Minnesota.

Bhavin B. Adhyaru is an Assistant Professor of Medicine at Emory University in Atlanta, Georgia.  He attended medical school at the University of Florida and completed his residency in Internal Medicine at Emory University.



References:

1. Weinberger M, Cytron S, Servadio C, Block C, Rosenfeld JB, Pitlik SD. Prostatic abscess in the antibiotic era. Rev Infect Dis. Mar-Apr 1988;10(2):239-249.

2. Brede CM, Shoskes DA. The etiology and management of acute prostatitis. Nat Rev Urol. Apr 2011;8(4):207-212.