A man in his late 40s with a 30 pack-year cigarette smoking history and no other comorbidities presents with failure to thrive.

He first presented to an outside institution in 2016 with haematuria and 3 months later with volume overload secondary to renal failure. Bilateral ureteral strictures, hydronephrosis and a small contracted bladder consistent with ketamine bladder syndrome were noted. Bilateral percutaneous nephrostomy tubes were placed. Cystoscopy and biopsy revealed severely inflamed bladder with denuded epithelium and eosinophilic bodies in the stroma. He presented to our institution 1 month later for second opinion.

The white cell count was 9.47×109/L, (normal 3.12–8.44 × 109/L), red count 4.01, (4.20–5.73 × 1012/L), haemoglobin 94 g/L (126–170 g/L), haematocrit 0.303 (0.372–0.479), platelet count 690×109/L (156–325 × 109/L). The sodium concentration was 128 (135–147 mmol/L), potassium 6.2 (3.2–5.2 mmol/L), chloride 105 (97–107 mmol/L), bicarbonate 18 (23–27 mmol/L), blood urea nitrogen 27.8 (2.5–7.14 mmol/L), creatinine 221 (53.04–106.08 μmol/L). Aspartate aminotransferase 89 (10–37 U/L), alanine aminotransferase 121 (9–50 U/L), alkaline phosphatase (ALP) 2943 (40–129 U/L), gamma-glutamyl-transferase 2079 (9–58 U/L). Total bilirubin 15.39 μmol/L (3.42–22.23 μmol/L), direct bilirubin 11.97 (0.0–5.13 μmol/L), indirect bilirubin 3.42 (3.42–15.39 μmol/L).

This patient had a 10-year history of consuming 4–5 g/day of ketamine intranasally.

Due to non-adherence with follow-up, continued ketamine use and disabling bladder spasms, he required cystectomy, distal ureterectomy, bilateral ureteral stent placement and ileal neobladder reconstruction in 2017. Sections of bladder showed a markedly thickened wall due to a combination of smooth muscle hypertrophy, intramural and perimural fibrosis, and inflammation. The inflammation was transmural and included notable eosinophils and mast cells. The bladder mucosa was extensively ulcerated. There were several foci of nephrogenic adenoma/metaplasia (confirmed by positive staining for PAX-8 and racemase). There were eosinophilic bodies in the submucosa of an unclear …