Renal Tuberculosis - Kidney and tubercular manifestations

Renal Tuberculosis - Kidney and tubercular manifestations

1. NEPHROLOGY CLINICAL SEMINAR: TUBERCULOSIS AND KIDNEY . 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.

5. 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.

6. 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.

7. 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.

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

9. 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 .

10. 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 .

11. 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.

12. 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.

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

14. 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.

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

16. Etiology Mycobacterium tuberculosis Rare organisms Mycobacterium kansasi Mycobacterium intercellulare Mycobacterium bovis Mycobacterium xenopi

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

18. 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.

19. 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 .

20. 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 .

21. 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.

22. 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.

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

24. 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.

25. 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

26. 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 .

27. 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

28. 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)

29. RADIOLOGY: PLAIN RADIOGRAPH Renal calcification

30. 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

31. 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).

32. 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.

33. 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.

34. 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.

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

36. 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.

37. 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

38. 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.

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

40. 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.

41. 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)

42. CT scan Calcified right kidney

43. Enlarged left kidney with multiple cavities present bilaterally

44. GROSS APPEARANCE

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

46. Acid fast bacilli Granulomatous changes

47. 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.

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

49. 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.

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