Correspondence

Case 27-1998: Eosinophilic Cystitis

N Engl J Med 1999; 340:1049April 1, 1999

Article

To the Editor:

In Case 27-1998 (Aug. 27 issue),1 Atala offers an excellent discussion of eosinophilic cystitis. However, this case illustrates a problem many readers have with the Case Records: namely, that consideration is rarely given to the appropriateness of the diagnostic workup. Did this 10-year-old girl really need to go through four separate catheterizations, an attempt to obtain a voiding cystogram that was clearly futile (given that she had repeatedly demonstrated her inability to void), two sonographic examinations, computed tomography, and magnetic resonance imaging before getting cystoscopy? Given that the leading diagnostic considerations were neoplasm or an inflammatory process, cystoscopy appears to have been indicated as an early intervention. In addition, no mention was made of her hypertension: was it simply obstructive, and did it resolve? Finally, she had borderline microcytic anemia: was her stool ever checked for ova and parasites, findings that could provide a cause for anemia and eosinophilic cystitis?

Duncan M. Kuhn, M.D.
9 Fifth St., SE, Washington, DC 20003

1 References

1
Case Records of the Massachusetts General Hospital (Case 27-1998). N Engl J Med 1998;339:616-622
Full Text | Web of Science | Medline

Author/Editor Response

Dr. Atala and a colleague reply:

To the Editor: Kuhn raises important questions about the appropriateness of the diagnostic evaluation. It should be noted that neither of us was the primary physician involved in the care of this young girl.

Kuhn questions whether the patient, a 10-year-old girl, required four separate catheterizations. She did, indeed, undergo catheterization a considerable number of times. However, it would have been inappropriate initially to leave an indwelling catheter inserted. The removal of the second catheter seems to have been warranted, given the patient's initial course. Whether the third catheterization should have been the last could be debated.

Should a voiding cystourethrographic study have been performed at all? Yes, given that an obvious lesion might well have been found, and given that the diagnostic possibilities, which we discussed, made it likely that a definitive diagnosis could be reached without anesthesia, which is appropriate for a 10-year-old girl if she is to undergo cystoscopy. Were two sonograms, a computed tomographic scan, and a magnetic resonance image needed? Probably not, but the retrospectroscope remains a powerful instrument.

Kuhn also notes that the patient had mild hypertension on her initial presentation but that nothing further was stated about it in the description of the case or its discussion. The child's hypertension resolved during her hospitalization without antihypertensive therapy and has not recurred. Finally, although her stool was not tested for ova and parasites, this step might have been worthwhile.

The patient has remained well for the nearly two years that have passed since her presentation, without any further episode of acute urinary retention.

Julie R. Ingelfinger, M.D.
Massachusetts General Hospital, Boston, MA 02114

Anthony J. Atala, M.D.
Children's Hospital, Boston, MA 02115

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