Emphysematous cystitis and spontaneous sigmoid colon perforation in a patient with steroid‐dependent nephrotic syndrome

Focal segmental glomerulosclerosis (FSGS) is one of the major causes of refractory nephrotic syndrome (NS). The main treatment strategy for FSGS is steroid therapy but steroid has many adverse effects (AE) and the risk increases with duration of steroid administration. We present a 65-year-old Japanese woman with chronic kidney disease stage G5A3 due to FSGS. Her course was complicated by repeated relapses and the administration period of steroid became prolonged as it became difficult to control. This time she was admitted under treatment of 6 relapse. On admission, elevation of inflammatory response was observed. Screening computed tomography (CT) was performed and emphysematous cystitis was detected. After insertion of transurethral catheter antibiotic therapy was started and the cystitis was treated successfully. On the 30 day, the patient complained of acute severe lower midabdominal pain. Again, screening CT was performed and the perforation of sigmoid colon was suspected (Fig. 1). She underwent emergency exploratory laparotomy and perforation of sigmoid colon was confirmed. The sigmoid was resected and an artificial anus was created. The postoperative course was noted for poor wound healing. Cumulative dose of steroid is known to be strongly associated with AE, especially when the cumulative dose exceeds 10 000 mg (prednisolone conversion). In our case, the cumulative dose well exceeded 10 000 mg. Steroid carries a risk of emphysematous cystitis but spontaneous perforation of the digestive tract is rare. Our patient was symptomatic and we were able to diagnose promptly, but long-term steroid administration can mask symptoms. We need to have low threshold for performing CT not only to detect severe complications early but also to prevent them.