An Unusual Cause of Haemorrhagic Cystitis in a Teenager with
Medulloblastoma
Haemorrhagic cystitis (HC) is a life-threatening condition in which the
transitional epithelium and blood vessels of the bladder necrose leading
to severe haematuria, abdominal pain and voiding lower urinary tract
symptoms1. Often occurring in immunosuppressed
patients, aetiology includes chemotherapy (cyclophosphamide, ifosfamide,
busulfan), radiotherapy or infectious agents (bacterial urinary tract
infection, adenovirus, BK polyomavirus (BKV) and
cytomegalovirus)2. In many cases no obvious cause can
be identified, but a number of risk factors have been reported in the
literature that predispose these patients to developing HC. The
incidence has a wide range between 3% and 35%, dependent on aetiology
and disparity between HC definitions used in
research3. Mild HC often resolves spontaneously
without complications, but moderate to severe HC may result in
life-threatening complications or death.
The mainstay of treatment lies with blood-clot evacuation with wide bore
urinary catheters and continuous bladder irrigation, hyperhydration with
intravenous fluids and supportive red cell and/or platelet
transfusion3. Oxybutynin often provides benefit and
sodium pentosan polysulphate (SPP) can be used to replace the damaged
glycosaminoglycan layer in the bladder4,5. Otherwise
management is specific to the underlying cause. For example, Mesna is
given alongside oxazaphosphorine chemotherapy as hepatic metabolism of
these agents forms acrolein, which is excreted in urine and leads to
ulceration and necrosis of the urothelium. Mesna binds acrolein and
prevents this. Viral infections can be managed supportively or treated
with antivirals. Evidence is emerging which supports the use of
hyperbaric oxygen in radiation-induced HC3. Treatments
such as oestrogen, intravesical alum, or formalin are sometimes
considered in difficult cases6,7,8.
We present a paediatric case of HC secondary to either cisplatin or
lomustine, both of which have never been reported to have HC as a side
effect.