52 y/o man with chronic urinary tract infections

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July 25, 2023

52 y/o man with chronic urinary tract infections

In this case, a 52-year-old man was referred to the urologist due to a marked decrease in the voiding stream caliber, postvoid dribbling, hematuria, and urinary retention. The patient's previous medical history includes multiple urinary tract infections, GERD, hyperlipidemia, and hypertension. During the rectal examination, prostatic enlargement was identified. Due to the symptom’s persistence, an abdominopelvic sonogram was performed yielding an acute cystitis. Subsequently, a biopsy was performed, and the microscopic evidence looks as follows.

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What is the most likely diagnosis?

a. Actinomycosis of the Urinary Bladder

b. Eosinophilic Granuloma of the Bladder

c. Malakoplakia of the Bladder

d. Granular Cell Tumor of the Bladder

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During macroscopic pathological analysis of the tissue, multiple yellow friable plaques (granulomas) in the mucosa were observed. Microscopically, there are abundant macrophages in the lamina propria that have large-polygonal, eosinophilic cytoplasm (Von Hansemann histiocytes), characterized by the calcified intracytoplasmic inclusion entities (Michaelis-Gutmann bodies). Typically, these cases are PAS positive because of the phagolysosomes containing fragments of incompletely killed bacteria with abnormal iron and calcium deposits. In this case, in addition to PAS, both Perls (iron) and von Kossa (calcium) stains were positive consistent with malakoplakia of the bladder.

Currently, 80% of malakoplakia cases occur in the genitourinary system, mainly in the bladder, followed by the ureter, pelvis, and renal parenchyma, although it can also affect other organs. Its incidence is extremely rare, and less than 500 cases have been reported. At present, malakoplakia’s treatment consists of antibiotics such as fluoroquinolones and trimethoprim-sulfamethoxazole; in pseudo-tumoral cases, surgical removal of the lesions is required.

References

Dong, H., Dawes, S., Philip, J., Chaudhri, S., & Subramonian, K. (2014). Malakoplakia of the Urogenital Tract. Urology case reports, 3(1),6–8. https://doi.org/10.1016/j.eucr.2014.10.002.

Stamatiou, K., Chelioti, E., Tsavari, A., Koulia, K.,Papalexandrou, A., Efthymiou, E., Tsilivigkou, M., & Vasilakaki, T. (2014). Renal failure caused by malakoplakia lesions of the urinary bladder. Nephro-urologymonthly, 6(4), e18522. https://doi.org/10.5812/numonthly.18522

Xiao, N., Tang, R., Ge, B., Zhao, H., & Wang, J. (2020). Poor bladder compliance due to malacoplakia with xanthogranulomatous cystitis: A case report. Medicine, 99(26), e20852. https://doi.org/10.1097/MD.0000000000020852.

Wang, H. K., Hang, G., Wang, Y. Y., Wen, Q., & Chen, B.(2022). Bladder malacoplakia: A case report. World journal of clinical cases, 10(23), 8291–8297. https://doi.org/10.12998/wjcc.v10.i23.8291.

Collaborators

José Lev AlvarezGómez, BS, MA, MA (Content), Juan C. Santa Rosario, MD (Edition and Images) and Dario Sanabria Bellassai (Peer Review Contribution).

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