Renal Tuberculosis - Kidney and tubercular manifestations

1. Guide : Dr Venkatesh Moger
Student: Dr Shruti C Bhojashettar

2. Case 1
 A 67 years old male patient was admitted to the Emergency
Room for abdominal pain, constipation by 36 hours.
 The clinical examination revealed the presence in the left
abdomen of a hard-elastic and fixed mass with irregular
margins and a longitudinal diameter of about 30 cm.
 Blood parameters showed a slight neutrophilia (11,450
white blood cells/ ml), blood urea nitrogen and serum
creatinine levels 54 mg/dl and 1.2 mg/dl respectively.

3.  Computerized tomography (CT) scan with contrast
medium of the thorax, abdomen and pelvis showed the
presence of a retroperitoneal mass of renal origin
completely filling the left retroperitoneal space, from the
subdiaphragmatic area to the iliac fossa, with displacement
of the spleen and the descending colon.

4. Computerized tomography scan with contrast medium of the thorax,
abdomen and pelvis showing the presence of a retroperitoneal mass of
renal origin completely filling the left retroperitoneal space, from the
subdiaphragmatic area to the iliac fossa, with displacement of the
spleen and the descending
Colon.

6. Case 2
A 34-year-old man sought medical attention due to a 6-
month history of
 dysuria,
 macroscopic hematuria,
 polyuria,
 and supra-pubic pain associated.
His symptoms continued after receiving different
antimicrobial treatments.
Had persistent negative urine cultures.

7.  Laboratory tests showed the following results:
 hemoglobin, 14mg/dL;
 white blood count, 5,100/mm³; platelets, 233,000/mm³;
 creatinine, 1.0mg/dL [estimated GFR = 98mL/min/1.73m2];
 urea, 39mg/dL; FBS 76mg/dL;
 uric acid, 5mg/dL;
 Urinalysis showed the following results:
pH 5.0
Leukocyturia (14/high power field),
hematuria (10/high power field),
and traces of protein.

8. • A routine urine culture did not yield any bacteria.
• Abdominal ultrasound revealed moderate dilation
of the right pelvilocaliceal system.
Tuberculin skin test was negative
Screening for acid-fast bacilli in the urine was positive in 5 of
the 10 samples
Positive culture for M. Tuberculosis proved the diagnosis.

9. Renal scintigraph showing the right kidney with reduced dimensions,
with heterogeneous distribution of radioisotope caption and no
evidence of excretion (obstructive pattern).

10. Case 3
 A 53-year-old man was admitted to the hospital because of
vomiting, generalised weakness, drowsiness of 2 days
duration.
 Physical examination revealed coarse and decreased breath
sounds on the right lung field.
 Patient attenders told he was started on medication for his
cough 1 month ago and since then patients urine colour
was changed to orange.
 Laboratory tests showed a
white blood cell count of 12,900: eosinophil 150/cumm:
hemoglobin of 9.7 g/dL.

11.  Blood urea nitrogen level of 40 mg/dL,
 Serum creatinine of 4.23 mg/dL,
 Urinalysis revealed 2＋ proteinuria, glycosuria, microscopic
hematuria and sterile pyuria.
 The patient’s urinary protein/creatinine ratio was 3,197
mg/g.
 Renal ultrasonography demonstrated that both kidneys
had a normal size range and echogenicity.

12.  Renal biopsy was performed, which showed atrophic,
degenerative changes and sloughing of tubules with
lymphocyte infiltration.
 Focal edema and fibrosis of the interstitium, and diffuse
infiltration of plasma cells, neutrophils, and macrophages.

14.  Exchanged out rifampin for levofloxacin.
 Three months later, the patient’s creatinine level was
within the normal range. Pyuria and glycosuria had
resolved and urinary protein/creatinine ratio was also
decreased to 247 mg/g.

15. RENAL TUBERCULOSIS
 Introduction
 Epidemiology
 Etiology
 Pathogenesis
 Clinical features
 Complications
 Investigations
 Treatment

16. Introduction
 Genitourinary TB is the second most common form of
extrapulmonary TB, after lymph node TB.
 Genitourinary TB occurs in about 5% of active TB cases in
the non–HIV-infected population
 GUTB has the propensity to affect both men and women
of child-bearing age (that is, 20–40 years old), is
responsible for extensive morbidity and can render patients
infertile.
 GUTB predominantly affects men (40–50 years of age),
with a prevalence twice that which is seen in women.

17. Epidemiology
 Genitourinary tuberculosis is diagnosed in 1.1% to 1.5% of
all tuberculosis cases, and 5% to 6% of cases of
extrapulmonary tuberculosis.

18. Etiology
 Mycobacterium tuberculosis
Rare organisms
Mycobacterium kansasi
Mycobacterium intercellulare
Mycobacterium bovis
Mycobacterium xenopi

19. Pathogenesis
 Route of infection: inhailation, rarely ingestion
 90% unilateral
 Hematogenous spread most common

20.  The clinical and pathologic manifestations of TB depend
on the virulence of the organism and the effectiveness of
the host response. The host response may lead to complete
containment of infection or result in an illness of varying
severity.
 A low serum level of 25-hydroxyvitamin D may also
compromise cell-mediated immunity and increase the risk
for activation of latent TB.

21.  Urinary TB may present as a miliary or ulcerocavernous
pathologic process.
 The miliary form of TB is rare and is seen particularly in
immunosuppressed individuals.
 The gross appearance of the kidney is characteristic; the
cortex is studded with yellowish white, hard, pinhead-sized
nodules that on microscopy show several coalescent
granulomas with central caseation.

22.  In the more common ulcerocavernous form, the kidneys
will initially appear normal or show yellow nodules on the
outer surface.
 On cut section, granulomas and ulcers in the renal
pyramid or medullary cavities may be seen.
 Larger cavities filled with caseous material communicating
with the collecting system may also occur.

23.  Other gross findings include multiple ulcers in the
infundibular region of the calyces, calyceal stenosis with
caliectasis, ulcers or strictures of the ureter with
hydronephrosis, pyonephrosis, subcapsular collections,
and perinephric abscesses.
 The bladder may show ulcers or be grossly fibrotic and
contracted.

24.  Other gross findings include
multiple ulcers in the infundibular region of the calyces,
calyceal stenosis with caliectasis,
ulcers or strictures of the ureter with hydronephrosis,
pyonephrosis, subcapsular collections, and perinephric
abscesses.
The bladder may show ulcers or be grossly fibrotic and
contracted.

27. Clinical features
Most common symptoms:
 Dysuria
 Hematuria
 Gross pyuria
 Flank pain
 Constitutional symptoms are less common

28.  Other symptoms: nocturia, suprepubic pain, scrotal or
epididymal mass, a penile ulcer.
 scrotal sinus discharging thin, watery and odorless pus
is highly suggestive of TB.
 Women: menstrual irregularity, abdominal pain,
infertility or pelvic inflammatory disease.

31.  Risk factors for urogenital tuberculosis
 Contact with TB infection
 TB of any other localization,
 Urinary tract infection (UTI) with frequent
recurrences and resistance to standard therapy
 Persistent dysuria and reduced bladder volume
 Sterile pyuria
 Pyospermia and/or hematospermia
 Scrotal, perineal, and lumbar fistulas

32. INVESTIGATIONS
• Tuberculin skin test
• Urine analysis: pyuria, hematuria,
• Isolation of M. tuberculosis by urine culture is the
definitive diagnostic test.
• Fully voided early-morning urine samples for 3 to 5
consecutive days are cultured on two standard solid
mycobacterial culture media: egg-based Lowenstein-
Jensen and agar-based Middlebrook .

33. • Radiometric broth method for acid-fast bacilli
isolation, a positive growth can be obtained in about 9
days.
• 50% of the cases show positive culture for other
organisms.
• Direct demonstration of acid-fast bacilli in urine by
Ziehl-Neelsen . (M. smegmatis, a saprophyte)
 Ultrasound-guided fine-needle aspiration cytology

34. Imaging study
 Plain radiograph
 Plain film findings focus on calcification, which is seen
in ~35% (range 25-45%), at various stages of disease:
 triangular in papillary necrosis
 focal or amorphous: putty kidney (end stage)

35. RADIOLOGY: PLAIN RADIOGRAPH
Renal calcification

36. Fluoroscopy
 Traditional plain film IVP is quite sensitive to renal tuberculosis
with only 10% of affected patients having normal imaging.
Features include:
 parenchymal scars 50%
 moth eaten calyces: early finding
 irregular caliectasis
 phantom calyx
 hydronephrosis
 Lower urinary tract signs include:
 Kerr kink
 sawtooth ureter
 pipe-stem ureter
 beaded or corkscrew ureter
 thimble bladder

37. EXCRETORY UROGRAM
 Abnormalities seen in 70% to 90%.
 Minimal erosion of the tip of the calyx with spasticity,
incomplete filling, distortion, infundibular stenosis,
hydrocalicosis, multiple ureteral strictures,
hydronephrosis, hydroureter, or nonvisualization of the
kidney may be present.
 The renal pelvis, which may be dilated initially, may
eventually be obliterated, leading to a distorted appearance
called “hiked-up pelvis” (Kerr kink sign).

38.  Irregularities or multiple strictures lead to a beaded or
corkscrew appearance of the ureter or hydronephrosis.
Later, thickening and straightening of the whole ureter
may occur (“pipe-stem” ureter).
 The bladder may appear irregular and fibrosed, and
VUR may occur.

39. Pyelography:
 Antegrade or retrograde pyelography can identify the
number, length, or site of ureteral strictures and assist
in placement of a ureteric stent across the stenotic
segment.

41. Plain film showing calcification in the
lower pole of the right kidney.
Five-min film showing an abnormal
calyx with some loss of renal
substance.

42. Twenty-min
film showing ureteric
dilation and stricture
and an irregular bladder
wall.

43. ULTRASOUND
 High-resolution ultrasound is useful to rule out
obstruction and to study the parenchyma closely to
identify granulomas, small abscesses, bladder mucosal
thickening, or calcification.
 The earliest finding is mucosal thickening and calyceal
irregularity.

44.  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

45.  end-stage
 small, shrunken kidney, "paper-thin" cortex and dense
dystrophic calcification in collecting system
 may resemble chronic renal disease
 Ultrasound is less sensitive than CT in detection of:
 calyceal, pelvic or ureteral abnormalities
 isoechoic parenchymal masses
 small calcifications
 small cavities that communicate with collecting
system.

46. Necrosed
papilla.
High-resolution
ultrasound scan
of the kidney
shows a sloughed,
necrosed papilla
(P) in the calyx.

47. Mucosal thickening (arrows) of calyces and the pelvis (P). There are calcifications
of the wall of the calyx and pelvis (arrowheads). A parenchymal cavity (C) is also
shown.

48. Ct scan
 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)

49. CT scan
Calcified right kidney

50. Enlarged left kidney with multiple cavities present bilaterally

53. GROSS APPEARANCE

56. Histologic diagnosis
Pathologic triad of
caseating necrosis,
loose aggregates of epithelioid histiocytes, and
Langhans giant cells

57. Acid fast bacilli Granulomatous changes

58. Surgical Treatment
 Two broad types of surgical treatments are considered.
 Reconstructive surgery involves the correction of
obstruction to the ureter by pyeloplasty,
ureteroureterostomy, correction of reflux by ureteral
reimplantation, and increasing the bladder capacity by
augmentation cystoplasty.
 Ablative surgery involves removal of the diseased parts
together with the infected material containing the
dormant organisms.

59.  Nephrectomy is advocated only in patients with
secondary sepsis, pain, bleeding, uncontrollable
hypertension, or continued positive urinary cultures .

60. MEDICAL THERAPY
 ATT
 Because streptomycin and ethambutol are excreted by
the kidney, dosage modification of these drugs is
necessary in renal failure. Streptomycin (15 mg/kg) is
administered every 24 to 72 hours for a GFR of 10 to 50
ml/min and every 72 to 96 hours for a GFR of less than
10 ml/min to maintain a therapeutic peak level of 20 to
30 μg/ml.

61. REFERENCES
 Comprehensive Clinical Nephrology :Richard J.
Johnson, MD, John Feehally, DM, FRCP.
 BRENNER & RECTOR’S THE KIDNEY.