A 63-year-old woman presented to the emergency department (ED) with a history of malaise, dysuria and urinary frequency of 1 week's duration. She denied fever, chills, nausea, cough or expectoration. She had type II diabetes mellitus (DM) and hypertension that were medically controlled. In the week prior to the ED visit, the patient gradually developed malaise. In addition, an altered mental state and unstable levels of blood glucose were noted. At the admission examination, her consciousness level was E3 V4 M6 according to the Glasgow Coma Scale. Her blood pressure was 237/118 mmHg, pulse rate 146 beats/min, body temperature 35.4°C, respiration rate 18 breaths/min, and blood glucose level 463 mg/dl. A physical examination revealed lower abdominal distension without tenderness or muscle guarding. Laboratory data showed a hyperosmolar hyperglycemic state without ketoacidosis, and aleukocytosis with an elevated C-reactive protein. Urinalysis showed a high white blood cell count with bacteriuria. An abdominal X-ray study showed a curvilinear area of radiolucency delineating the urinary bladder wall (Fig. 1). Emergency abdominal computed tomography (CT scan) showed multiple punctate foci of gas delineating the bladder wall (Fig. 2). No colovesical fistulas, adjacent neoplasms, emphysematous ureteritis, or pyelonephritis was observed in the images. With the presumptive diagnosis of emphysematous cystitis (EC), the patient was treated with a third-generation cephalosporin. A urine culture yielded Escherichia coli, but the blood cultures showed no growth of bacteria. After antibiotic treatment for a few days, the patient's general condition and consciousness level had significantly improved. A follow-up abdominal X-ray revealed the disappearance of the gas around the bladder.Emphysematous urine tract infections (UTIs) can manifest as cystitis, ureteritis, pyelitis, or pyelonephritis. The severity of the disease is due to the level of gas based upon the findings on CT scans. Diabetes mellitus is the major risk factor for emphysematous urine tract infections (prevalence, 62-66%) [1]. Middle age (mean age, 60 years old), female gender (female-to-male ratio of 2:1), urinary tract pathology (neurogenic bladder or recurrent UTI), and immunosuppressive comorbidity (malnutrition, alcohol abuse, or malignancy) are also known risk factors. The clinical presentation of EC is non-specific and can range from asymptomatic UTI to septic shock. The common presenting features include abdominal pain (80%), pneumaturia (70%), and abdominal tenderness (65%). However, the typical symptoms for lower urine tract infections, including urination frequency, urgency, and dysuria, are only seen in up to 50% of cases [2]. Because the clinical features are inconclusive, the symptoms are of no help in
