Case Presentation: A 68 year old male with a history of end stage renal disease (ESRD) on hemodialysis, s/p cardiac transplant for refractory ischemic cardiomyopathy, and Cerebrovascular accident presented to the emergency department (ED) with fevers, lethargy and penile discharge. In the ED, he ws noted to be febrile with a temperature of 102.7 ºF.  He had no frank hematuria, flank pain, chest pain, shortness of breath, or abdominal pain. His medications included the immunosupressants; cyclosporine and mycophenolate.                                                                                                             His heart rate was 86/min, Blood pressure was 102/53mmHg. He was not tachypneic.  He appeared chronically ill-looking with a mild degree of pallor but was anicteric.  Chest: Normal breath sounds. CVS: Regular heart sounds, no  murmurs or rub. Abdomen: Not distended. Soft, not tender. Bowel sounds: normal. Genito-urinary: No costo-vertebral tenderness but had mild suprapubic tenderness. CNS: Awake and alert. No motor deficits noted.  Extremities: No edema.

Lab data: WBC: 5.9, Hemoglobin was 9.3 and Platelet count was 110,000. Serum Creatinine was 4.32mg/dl, Blood urea nitrogen was 21mg/dl. Head CT scan was unremarkable.  Serum cyclosporine was within normal range A foley catheter was placed and drained blood stained purulent material.  Renal ultrasound showed atrophic kidneys, and echogenic debris within the urinary bladder with no evidence of flow.  The patient was seen by his Urologist, and he was started on intravenous ceftriaxone, and scheduled bladder irrigations with gentamicin and normal saline. After three days of irrigation his fever and lethargy resolved. Culture of the fluid revealed greater than 10,000 colonies of pan-sensitive Trueperella Bernardiae. He was transitioned to PO antibiotics and discharged home.

Discussion: Pyocystis is a common yet overlooked source of infection among anuric patients. The primary pathogenesis of this infection is from reduced washout of the urinary bladder. Lack of diuresis leads to leads to defunctionalization of the bladder, and the ensuring fluid stasis also promotes extensive bacterial colonization. These factors create a microenvironment in which the bladder wall is prone to abscess formation. Susceptibility is further enhanced with comorbid conditions including diabetes mellitus and/or use of immunosuppressants.

This is the first case to report pyocystis due to Trupurella Bernardiae species. This organism was first described by the CDC as an opportunistic pathogen belonging to the cornyeform group 2 bacteria genus. It was reclassified into the arcanobacteriumgenus in 1995, and finally, into the newly created Trueperella genus in 2011. Trupurella bernardiae is a predominantly facultative anaerobic gram positive coccobacili that is non-motile and nonsporulating. This organism is catalase negative and does not cause nitrite production in the urine.

Conclusions: Bladder infections are not frequently thought off in patients with ESRD. There is the notion that patients with ESRD who are oliguric can not have urinary bladder infections. This case illustrates the need for Hospitalists to seriously consider such infections especailly in patients with ESRD who are immunocompromised.  Patients who are immunosuppressed, may not mount the required pyuria when they have bladder infections. Overlooking these cases of cystitis may results in pyocystis and/or sepsis .