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.