Renal tuberculosis

1. Renal Tuberculosis
Dr.I.Gurubharath MD PhD Dr.Pooja

2. Renal Tuberculosis
Renal TB in 5–10% of patients with pulmonary TB
Radiographic evidence of pulmonary TB in < 50% of patients
with renal TB
Location: unilateral (75%)
Renal size: enlarged (early) / small (late) / normal (most
common)

3. Infection limited to the renal parenchyma has two
morphological appearances
Pyelonephritis
Appearances are similar to pyelonephritis caused by other
organisms
Hypoperfusion and swelling of all or part of the kidney
Pseudotumoural type
Single or multiple nodules
Mimics renal cell carcinoma

4. Early
Papillary necrosis(single or multiple) resulting in uneven
caliectasis
Progressive
Multifocal strictures and hydronephrosis
Mural thickening and enhancement (on cross-sectional
imaging)
End-stage
Progressive hydronephrosis and parenchymal thinning
Dystrophic calcification

5. Plain radiograph
Plain film findings focus on calcification
• Triangular in papillary necrosis
• Focal or amorphous: putty kidney(end stage)

7. Radiograph showing putty kidney

8. Fluoroscopy
• Parenchymal scars 50%
• Moth eaten calyces : early finding
• Irregular caliectasis
• Phantom calyx
• hydronephrosis
Lower urinary tract signs
Kerr kink
sawtooth ureter
pipe-stem ureter
beaded or corkscrew ureter
thimble bladder

9. Moth eaten kidney appearance on IVU

10. Golf ball appearnace

11. Papillary necrosis

12. An upward pointing
renal pelvic
calculus suggesting
presence of a hiked
up renal
pelvis.Multiple
discrete
calcifiactions are
noted in an upper
polar tb cavity

13. Phantom Calyx

14. Kerr kink

15. Multiple renal parenchymal cavities (black arrows) with areas of papillary
necrosis (white arrow) l upper pole of calyceal outline is destroyed by adjacent
granulomatous tissue

16. Hiked up pelvis(arrow) TB cavity(white arrow heads) communicating with upper group
of calyceas.(black arrow)head medial border of compound pelvis.
Fluffy cavities (white arroeheads communicating with compund upper calyx odd
shaped pocket of contrast communicating with the lower calyx represe caseating
necrotic cavities

17. Infindibular stenosis IVP reveals infundibular n calyceal stricture with cortical scarring.
Pyleosinsus extravasation of contrast in the kidney suggest that fragile calyces.

18. A nonfunctioning lt kidney B. Nonfunctioning lt kidney infundibular scarring(white
arrowheads) uneven caliectassi. Low ureteric stricture n small capacity bladder

19. Delayed phase of intravenous urogram with a non-functional (L) kidney opacified
retrogradely: Developing lobar caseation in the U/3 of the (L) kidney (black
arrowheads). Note assimilation of the dilated calyces into the renal parenchyma.
Ragged hydrocalicosis(indicative of marked urothelial thickening) noted in the lower
half of the (L) kidney (arrows). Parenchymal demarcation is still clear adjacent to the
same (dotted line represents the non-visualized left renal outline). (R) renal papillary
necrosis is also seen (circled area) and so are calcified (L) paraspinal lymph nodes
(white arrowheads)

20. A) Intravenous urogram revealing calcified (L) psoas abscess (black arrow),
impinging on the ureter and a calcified caseous renal mass (arrowheads); more
apparent on nephrotomography

21. Pyelo cavitory and
plelolymphatic reflux noted in
retrograde pyelography

22. Bilateral percutaneous nephrostomogram revealing multiple filling defects along the
upper ureter bilaterally representing submucosal granulomas(empty arrow heads)the
large filling defects noted in the r urter is a calculus .the high density contrast in the
collecting system is obscuring submucosalgranulomas. However irregularites along the
medail pelvic margin gives clue of submucosal granuloma

23. Ureteric stricture(white) with ureteric calcificatiion (blavk arrow heads) pseudo caculi
(blackarrow) m irrugalr calcification in the parenchyma)

24. Saw tooth
appearance of
ureter

26. Lead pipe ureter

28. Ultrasound
Early
normal kidney or small focal cortical lesions with poorly
defined border
+/- calcification
Progressive
• Papillary destruction with echogenic masses near calyces
• Distorted renal parenchyma
• Irregular hypoechoic masses connecting to collecting system;
no renal Pelvic dilatation
• Mucosal thickening +/- ureteric and bladder involvement
• Small, fibrotic thick-walled bladder
• Echogenic foci or calcification (granulomas) in bladder wall
near Ureteric orifice
• Localised or generalised pyonephrosis

29. End-stage
Small, shrunken kidney, "paper-thin" cortex and dense
dystrophic calcification in collecting system
may resemble chronic renal disease

31. A) USG revealing tuberculosis granulomas of varying sizes (white arrows), (B) USG
revealing larger granulomas– the granulomas are highlighted by the vascular “cut-off”
(white arrows) noted on this color flow image

32. (A) High-resolution ultrasound images (acquired with a 7.5 MHz transducer)
demonstrate a small irregular caseous cavity (white arrow) in the upper part of
the left renal parenchyma, (B) high-resolution ultrasound images revealing a
tuberculous cavity with fine septae within, in the lower part of the left kidney of
another patient. Note marked urothelial thickening in this dilated system,

33. (C) USG image revealing irregular sonolucent cavities, with a semisolid echo texture

34. (USG image revealing irregular sonolucent cavities, with a semisolid echo
texture. USG image revealing an xanthogranulomatous pyelonephritis-like
appearance in an enlarged tuberculous kidney

35. (A) USG image revealing a caseating tuberculous granuloma, communicating with a
calyx via a narrow tract (white arrows),

36. Focal calviectatsis

37. A) Moderate-to-severe urothelial thickening noted throughout the visualized
urothelium. This is well visualized on account of the dilatation due to a tuberculous
ureteric stricture, (B) USG image revealing uneven caliectasis with ragged urothelial
thickening (arrowheads). Note significant debris in the lower calycesIrregular
pelvicalictesis with urothelial thickening

38. USG image showing evolution of tuberculous lobar caseation. Different phases of
destruction are apparent. (Lower group calyces are completely merged with the
parenchyma, midgroup calyces about to merge, and upper ones almost merged).
Arrowheads demarcate the junction between residual parenchyma and the dilated
calyces

39. Caseous necrosis (A) USG image revealing lobar caseation (A) Grey scale and, (B)
Color flow image demonstrating presence of renal vasculature only between the
caseated lobes

40. (A) USG image revealing left tuberculous perinephric collection due to a ruptured
upper polar tuberculous abscess. (A) Grey scale image, (B) USG image revealing left
tuberculosis perinephric collection due to a ruptured upper polar tuberculous abscess.
Color flow image revealing lateral extent of the renal parenchymaPerinephric abscess

41. Renal scarring

42. CT
Early
Papillary necrosis (single or multiple) resulting in uneven
caliectasis
Progressive
Multifocal strictures can affect any part of the collecting
system
Generalised or focal hydronephrosis
Mural thickening and enhancement
Poorly enhancing renal parenchyma, either due to direct
involvement or due to hydronephrosis
end-stage
Progressive hydronephrosis results in very thin parenchyma,
mimicking multiple thin walled cysts
amorphous dystrophic calcification eventually involves the
entire kidney (known as putty kidney)

43. Contrast enhanced nephrographic phase CT shows dilated calices and thining of the
renal cortex with thin calcifications.

44. CT revealing parenchymal granulomas (black arrows) in the (L) kidney with uneven
caliectasis and ureterectasis accompanied by urothelial thickening (white arrow).
Note the hypoperfused renal parenchyma and complete loss of corticomedullary
differentiation in the (L) kidney

45. CT revealing caseous TB cavity (arrow) in the upper pole of the (L) kidney: (A) axial
and (B) coronal sections (MIP image). Note non-functioning hydronephrotic (R)
kidney, with a scarred renal pelvis, in (B), which is a delayed scan

46. CT revealing Left TB renal abscess (arrow) with minimal perinephric spread
(arrowheads) in (A). The left psoas muscle is involved, better appreciated in (B),
Retroperitoneal fascial thickening, fat stranding, and small left paraaortic lymph
nodes are also noted with a loss of corticomedullary differentiation of the affected
area in the (L) kidney

47. CT revealing (A) focal renal
cortical scarring (arrows) and (B)
focal cortical thinning (C) diffuse
cortical scarring of the (L) renal
cortex. Renal pelvic scarring and
resultant caliectasis are also noted

48. A) Axial and (B) coronal CT images revealing lobar caseation of the (L) kidney. Note
assimilation of the calyces into the renal parenchyma. The calyces in the (R) sided
hydronephrosis communicate with each other and are clearly demarcated from the
renal parenchyma. Note the stricture of distal ureter with resultant proximal dilatation

50. Fat-saturated T2W FSE sequence MRI image showing multiple small hypointense
granulomas (thin white arrows) in the (R) kidney. The (L) kidney shows caliectasis
with heterogeneous intermediate signal within on T2W images, due to caseous
internal debris (thick arrow)

51. Fat-saturated T2W FSE sequence MRI image showing small, slightly hyperintense,
caseating granulomas (curved arrows), and a tiny hypointense non-caseating
granuloma (arrow)

52. (A) axial and (B) coronal fat-saturated
T2W FSE sequence and (C) post-
contrast axial T1 fat-saturated MRI
imagesshowing a TB cavity
(arrowheads) communicating with
dilated calyces. Note small peripheral
non-enhancing hypointense lesion,
suggestive of a granuloma (white
arrow). An enlarged pyramid is also
noted (black arrow)

53. Fat-saturated T2W coronal MRI image of TB pyonephrosis revealing a scarred renal
pelvis and marked dilatation of the collecting system with severe parenchymal loss

54. Treatment and prognosis
Multi-drug treatment is essential
Nephrectomy, partial nephrectomy or cavernostomy can be
performed both open and endoscopically .

55. Differential diagnosis
General imaging differential considerations include:
Papillary necrosis
Medullary sponge kidney
TCC (transitional cell carcinoma) of renal tract
SCC (squamous cell carcinoma) of renal tract
Xanthogranulomatous pyelonephritis (XGP)

59. References:
1. Adam A, Dixon AK, Gillard JH, Schaefer-Prokop C, Grainger RG,
Allison DJ. Grainger & Allison's Diagnostic Radiology E-Book. Elsevier
Health Sciences; 2014 Jun 16.
2. Dahnert WF. Radiology review manual. Lippincott Williams & Wilkins;
2017 Mar 9.
3. Merchant S, Bharati A, Merchant N. Tuberculosis of the genitourinary
system-Urinary tract tuberculosis: Renal tuberculosis-Part I. Indian J
Radiol Imaging 2013;23:46-63
4. www.Radiopedia.org