|Year : 2014 | Volume
| Issue : 1 | Page : 47-49
Inflammatory pseudotumor of the bladder in a child
Rajendra B Nerli, Ajay K Guntaka, D Shishir, P Patne, Sujata M Jali, Murigendra B Hiremath
Department of Urology, KLES Kidney Foundation, KLE University's JN Medical College, KLES Dr. Prabhakar Kore Hospital & MRC, Belgaum, Karnataka, India
|Date of Web Publication||7-Feb-2014|
Rajendra B Nerli
Department of Urology, KLES Kidney Foundation, KLE University's JN Medical College, KLES Dr. Prabhakar Kore Hospital & MRC, Belgaum - 590 010, Karnataka
Source of Support: None, Conflict of Interest: None
Inflammatory pseudotumors of the bladder are rare in children. We report here the case of an 11-year-old child who presented with lower urinary tract symptoms. Ultrasonography and computed tomography imaging of abdomen showed an intravesical mass/thickening arising from the right lateral wall. Biopsy of the lesion revealed a lesion that showed uniform elongated spindle cells within a background of myxoid stroma. The cells were loosely packed from a smooth muscle lesion, which had a densely packed cellular stroma. The child improved with a course of antibiotics and a repeat imaging showed disappearance of the lesion.
Keywords: Bladder, children, inflammatory, pseudotumor
|How to cite this article:|
Nerli RB, Guntaka AK, Shishir D, Patne P, Jali SM, Hiremath MB. Inflammatory pseudotumor of the bladder in a child. J Sci Soc 2014;41:47-9
| Introduction|| |
A number of pathological conditions of the bladder can manifest as a focal bladder mass or diffuse wall thickening. These focal masses may be neoplastic or may develop secondary to congenital, inflammatory, idiopathic, or infectious sources. Clinical, macroscopic, and radiologic findings for these masses may overlap; making histological assessment mandatory to establish the diagnosis. Some of these entities, such as inflammatory pseudotumor, endometriosis, Crohn disease, and filling defects such as ureteroceles, have radiologic features suggestive of the diagnosis and may be first suspected by the radiologist. Diffuse bladder wall thickening can develop secondary to many non-neoplastic conditions, including infection with bacteria or adenovirus; schistosomiasis; tuberculosis; inflammatory conditions such as cystitis cystica, cystitis glandularis, or eosinophilic cystitis; and exposure to chemotherapy (particularly with cyclophosphamide) or irradiation.  Although the radiologic characteristics of these disorders are less specific, radiologic evaluation is still of value.
These pathological conditions may affect different portions of the bladder wall and hence it is important to be familiar with its histologic layers. The bladder wall consists of four layers namely uroepithelium, the lamina propria, muscularis propria and serosal covering formed by the peritoneum, which is present only over the bladder dome. The bladder is suspended within the extraperitoneal space and is surrounded by pelvic fat. We report a case of localized bladder wall thickening presenting as urinary incontinence in a child.
| Case Report|| |
An 11-year-old male child presented to the urological clinics of the hospital with symptoms of frequency, urgency, urge incontinence, and dysuria of 15 days duration. Routine urinary examination revealed presence of a few white blood cells/high power field. Abdominal ultrasonography [Figure 1] revealed a solitary exophytic bladder mass/thickening affecting the right lateral wall extending onto the dome. Computed tomography (CT) [Figure 2] revealed lobulated mass arising from the right lateral wall of the bladder. Cystoscopy revealed smooth normal appearing mucosa, except for a small area of 2 cm × 2 cm on right lateral wall which appeared reddish. There was an external pressure effect on the right lateral wall. Multiple biopsies were taken and sent for histo-pathological examination (HPE). The child was put on a course of antibiotics and was discharged. HPE [Figure 3] showed an uniform elongated spindle cells within a background of myxoid stroma. The cells were loosely packed from a smooth muscle lesion, which had a densely packed cellular stroma. Repeat ultrasonography and CT imaging was done after 1 month. The lesion had completely disappeared leaving a normal appearing bladder [Figure 4].
|Figure 1: Ultrasonography of bladder reveals thickening of the right lateral wall (upto 14 mm) and a poorly defined hypoechoic submucosal lesion at the dome (1.2 cm × 1.9 cm × 1.4 cm)|
Click here to view
|Figure 2: Computed tomography imaging reveals asymmetrical irregular bladder wall thickening (1.5 cm) along the right lateral wall with homogenous enhancement|
Click here to view
|Figure 3: Histo-pathological examination reveals uniform elongated spindle cells within a background of myxoid stroma. The cells were loosely packed from a smooth muscle lesion, which had a densely packed cellular stroma|
Click here to view
|Figure 4: Post-operative computed tomography imaging reveals smooth bladder wall|
Click here to view
| Discussion|| |
An inflammatory pseudotumor is a non-neoplastic reactive proliferation of myofibroblastic spindle cells and inflammatory cells with myxoid components. Affected patients usually present with an ulcerating bleeding mass, hematuria, and voiding symptoms. Other symptoms include fever and iron deficiency anemia. This condition is more common in adults, with the mean age at diagnosis reported to be 38 years, with a range of 15-74 years.  The condition may have a male predominance, as the male-to-female ratio was 11:6 in one series of 17 patients.  Inflammatory pseudotumors are rare in children, and one case has been reported in a neonate.  Nearly 37 such cases have been reported in pediatric age group.  However, in children sex predominance is not seen. Cystoscopy usually reveals a polypoid mass or a submucosal nodule, predominantly arising from the base, dome and anterior or lateral walls.
The etiology of inflammatory pseudotumors remains unclear. It has been suggested that altered regulation of cytokine expression may have a role in pathogenesis.  In bladder this entity has been associated with urinary tract infection or previous surgery or trauma, but in most children, no etiologic factor has been determined. , Angulo et al.  has suggested that this lesion might represent a reactive lesion arising from a histogenetic remnant of bladder roofing or posterolateral bladder delineation.  Conservative treatment appears to be the most appropriate management.
| References|| |
|1.||Wong-You-Cheong JJ, Woodward PJ, Manning MA, Sesterhenn IA. From the Archives of the AFIP: Neoplasms of the urinary bladder: Radiologic-pathologic correlation. Radiographics 2006;26:553-80. |
|2.||Iczkowski KA, Shanks JH, Gadaleanu V, Cheng L, Jones EC, Neumann R, et al. Inflammatory pseudotumor and sarcoma of urinary bladder: Differential diagnosis and outcome in thirty-eight spindle cell neoplasms. Mod Pathol 2001;14:1043-51. |
|3.||Asanuma H, Nakai H, Shishido S, Tajima E, Kawamura T, Morikawa Y, et al. Inflammatory pseudotumor of the bladder in neonates. Int J Urol 2000;7:421-4. |
|4.||Rohrlich P, Peuchmaur M, Cocci SN, Gasselin ID, Garel C, Aigrain Y, et al. Interleukin-6 and interleukin-1 beta production in a pediatric plasma cell granuloma of the lung. Am J Surg Pathol 1995;19:590-5. |
|5.||Roth JA. Reactive pseudosarcomatous response in urinary bladder. Urology 1980;16:635-7. |
|6.||Lakshmanan Y, Wills ML, Gearhart JP. Inflammatory (pseudosarcomatous) myofibroblastic tumor of the bladder. Urology 1997;50:285-8. |
|7.||Angulo JC, Lopez JI, Flores N. Pseudosarcomatous myofibroblastic proliferation of the bladder: Report of 2 cases and literature review. J Urol 1994;151:1008-12. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4]