RADIANCE PRESENTATION TB. A case of acute renal failure

A case of renal failure- GUTB

1. A case of ACUTE RENAL FAILURE

2. biodata Name : Zuhara n k Age : 68 Place : Perumbavoor

3. Presenting complaints Lower abdominal pain x 2 weeks Dysuria x 2 weeks Fever x 2 weeks Nausea , vomiting x 2 weeks

4. History of presenting illness 68 year old female presented with complaints of lower abdominal pain since two weeks which was insidious in onset and progressive in nature and radiating to the groin. It was associated with dysuria. No history of jaundice, abdominal distension. Patient also complaints of fever of 2 week duration, high grade fever initially associated with chills and rigor. No diurnal variation, continuous type of fever. No history of arthralgia, rashes over body

5. She also complains of nausea since 2 weeks associated with few episodes of vomiting, non bilious and non blood stained. No history of loose stools, food intake from outside. She consulted nearby clinic initially for the management of above symptoms, she was diagnosed with urinary tract infection and was treated with oral antibiotics and analgesics. S. Creatinine not checked at this time. Few days after completing her medications, she again developed same symptoms . Her S. Creatinine at that time was 6mg/dl.

6. She was again managed with antibiotics for one more week. Even after treatments her symptoms persisted and was found to have rapidly worsening renal function( s. creatinine-10mg/dl). Patient was seen by a local doctor and advised she may need dialysis. At that day for 1 day she has decreased urine output.

7. Past history Patient is a known case of systemic hypertension for 40 years Patient had intracranial aneurysmal bleed and had undergone coiling 4 years back Not a diabetic

8. Personal history mixed diet Normal appetite Adequate sleep Normal bowel and bladder habits(decreased urine output last 1 day) No history of any addictions

9. Family history history of diabetes , hypertension in the family

10. Old lady k/c/o Hypertension for last 40years presented with symptoms of urinary tract infection and with acute worsening of renal function in the form of increased S. Creatinine ( from normal ->6mg/dl->10mg/dl )

11. General physical examination Patient conscious , oriented Looks ill Pallor (+) , facial puffiness(+), bilateral pedal edema (+) No icterus, cyanosis, clubbing, lymphadenopathy Vitals Pulse Rate: 78 bpm , Blood Pressure : 110/60mmhg , RR : 14/’ , Temp : 98.6F

12. Gastrointestinal system Abdomen : soft , suprapubic tenderness(+) no renal angle tenderness uniformly distended, no shifting dullness no hepatosplenomegaly bowel sounds(+)

13. Respiratory system Trachea central Movement of chest bilaterally symmetrical and equal Normal vesicular breath sounds, clear

14. CARDIOvASCULAR sYSTEM S1S2 heard, Normal Apex beat normally heard at 5 th Intercostal space- 1 cm medial to midclavicular line No murmurs

15. Nervous system examination Higher mental function – within normal limits Cranial nerves – normal Motor and sensory system- normal Skull and spine –normal

16. PROVISIONAL DIAGNOSIS URINARY TRACT INFECTION WITH ACUTE DETERIORATION OF RENAL FUNCTION ?ANALGESIC INDUCED-NOT ON NEPHROTOXIC ANTIBIOTICS

17. investigations CBC 1/12/ 2023 3/12/2023 11/12/2023 HB 7.2 7.8 8.2 TC 5930 5290 5980 N/ L/E 77.7/13.5/ 0.4 PLATELET 2.64 2.3 1.9 MCV 88.5 MCH 28.4 MCHC 32 ESR 74 CRP 5.1 3.2

18. 1/12/2023 3/12/2023 7/12/2023 13/12/2023 S. CREATININE 13.3 7 5.3 6.6 S. UREA 185 150 70 106 NA+ 128 141 136 134 K+ 5.3 3.7 3.2 3.4 CA2+ 8.5 MG2+ 2 2 PO4 7.38 2.4

19. 1/12/2023 13/12/2023 TOTAL PROTEIN 7.2 6 ALBUMIN 2.8 2.7 GLOBULIN 3.4 3.3 A/G RATIO 0.82 T. BILIRUBIN 0.4 1.5 D. BILIRUBIN 0.4 1.4 AST 41 25 ALT 14 19 ALP 77 74 TSH 0.51

20. PERIPHERAL SMEAR REPORT: NORMOCYTIC NORMOCHROMIC ANEMIA URE shows few pus cells(6-8) URINE CULTURE : NO GROWTH ECG : NORMAL SINUS RHYTHM ECHO : CONCENTRIC LVH, NO RWMA, GOOD LV FUNCTION, MILD PAH

21. CHEST X RAY

22. COURSE IN THE HOSPITAL She was initially managed in the MICU. In view of rapidly worsening renal function( S .Creatinine -6.2 1013.3) ,and reduced urine output, Nephrology consultation was done and suggested hemodialysis and Renal biopsy to know the reason for rapidly progressive renal failure . Renal biopsy was done. USG abdomen showed right hydroureteronephrosis. After urology consultation CT KUB was done which showed relatively small left kidney and right hydroureteronephrosis DJ stenting done after 2 cycles of hemodialysis.

23. RENAL BIOPSY REPORT GRANULOMATOUS INTERSTITIAL NEPHRITIS WITH SEVERE TUBULAR ATROPHY C3 and c4 was normal ANA-IFA (+)

24. RENAL BIOPSY SLIDES INTERSTITIAL Dense Inflammatory Infiltrates

25. EPITHELIOD GRANULOMA

26. LANGHANS CELL

27. CAUSES OF GRANULOMATOUS INTERSTITIAL NEPHRITIS TB SARCOIDOSIS FUNGAL INFECTIONS DRUGS Renal Biopsy shows features of EPITHELIOID GRANULOMA WITH LANGHANS CELLS suggestive of TB, but there is no CASEOUS NECROSIS . TB being so common in our place we suspected TB.

28. Suspecting GUTB, urine AFB (3 samples) , urine TRUNAT was sent. 2 samples of urine AFB and urine TRUNAT came as positive. Sputum AFB and TRUNAT samples were sent- sputum TRUNAT came as positive.

29. Urine AFB trace positive

30. ATT was started on 12/12/2023 with renal adjusted dose. Tab. Isoniazid 300 mg daily Tab. Rifampicin 600 mg daily Tab. Ethambutol 800mg alternative days Tab .Pyrazinamide 750mg on every third day Tab .Wysolone 30mg OD was started for interstitial nephritis, Which was tapered and stopped accordingly.

31. 3 cycles of hemodialysis was done – dialysis catheter kept in situ as advised by nephrologist. Patient was discharged on 14/12/2023 Patient was on our follow up and her ATT was changed according to LFT derangement. 1 week back her dialysis catheter was removed as no further dialysis needed as per nephrologist

32. DIAGNOSIS DISSEMINATED TB GRANULOMATOUS INTERSTITIAL NEPHRITIS- HEMODIALYSIS INITIATED ON 02/12/2023 RIGHT HYDROURETERONEPHROSIS- S/P DJ STENTING(07/12/2023) URINARY TRACT INFECTION INTRACRANIAL ANEURYSMAL BLEED- S/P COILING 4 YEARS BACK SYSTEMIC HYPERTENSION

33. Tuberculosis is the most common cause of infection related death globally. Around 5 -45% of TB cases have extra pulmonary manifestations, and in those 30 -40% cases involve the urogenital tract The patients clinical presentation with GUTB may vary from asymptomatic to non- specific symptoms related to the organ involved. Granulomatous inflammation in biopsy tissue and presence of acid fast bacilli are hallmarks of TB.

34. TREATMENT GUTB , in general is treated like pulmonary TB for 6 months . Patient that may need longer treatment include patients with HIV co-infection, kidney abscess or bone infiltration.

35. COMPLICATION Superadded infection Strictures and fistula Renal hypertension and Chronic renal failure Infertility Prostatic abscess

36. PROGNOSIS Prognosis of GUTB is excellent if detected early and if patient has good compliance with ATT. Cure rate with appropriate ATT is around 90%.

37. THANK YOU