With approximately 9 million new cases being diagnosed each year, tuberculosis is globally an important disease that is primarily causing infections in the African and Asian continents, and only a minority of patients are from Europe and the United States of America [1] [2]. Apart from pulmonary tuberculosis, many extrapulmonary forms of the disease have been described in the literature, and one of the most important and most common is renal tuberculosis, comprising from 15%-27% of all extrapulmonary cases [1] [2] [3]. The pathogenesis stems from hematogenous spread of M. tuberculosis from the lungs to the kidneys, often in the absence of symptoms that could suggest an ongoing process in the pulmonary system [1]. After a variable incubation period, the clinical presentation of renal tuberculosis resembles a urinary tract infection (UTI) - dysuria, nocturia, pain in the flank, abdomen, or pelvis [1] [2] [3] [4]. Hematuria, appearing as an isolated symptom, is an important clue toward renal tuberculosis, but it may also be accompanied by proteinuria and sometimes pyuria [2] [3] [4]. Typical symptoms encountered in pulmonary tuberculosis, such as fever, weight loss, and night sweats are uncommon [1]. However, more severe infections can lead to marked kidney damage, resulting in obstructive uropathy and loss of kidney function that progresses to renal failure and end-stage renal disease [2] [3] [5]. For this reason, an early diagnosis is vital.

• Chills

  Other symptoms include chills, fever and frequent urination, sometimes there can be blood in the urine (this is called hematuria). Renal tuberculosis can be classified using two criteria. [tuberculosistreatment.blogspot.com]

  He denied a history of fevers, chills, night sweats, weight loss, or back pain. Past urinalyses demonstrated sterile pyuria. The patient reported a remote history of positive purified protein derivative test without treatment. [journals.lww.com]

  Case Presentation A 25-year-old adult male was admitted to hospital with complaints of continuous low grade fever since 2 months with chills, rigors and sweating. Patient complained of cough since 15 days and vomiting. [pubs.sciepub.com]

  Signs and symptoms of active TB include: Coughing that lasts three or more weeks Coughing up blood Chest pain, or pain with breathing or coughing Unintentional weight loss Fatigue Fever Night sweats Chills Loss of appetite Tuberculosis can also affect [mayoclinic.org]

  Malaise, fevers, and chills are also common in affected patients. Voiding problems are usually absent when only the external genitalia are involved. However, associated renal, vesical, or prostatic TB may contribute to irritative voiding symptoms. [emedicine.medscape.com]

• Fatigue

  P., a married white male, aged 37 years, was admitted to the Latter-Day Saints Hospital on January 10, 1940, complaining of occipital headaches of extreme degree, fatigue, shortness of FULL TEXT [annals.org]

  Signs and symptoms of active TB include: Coughing that lasts three or more weeks Coughing up blood Chest pain, or pain with breathing or coughing Unintentional weight loss Fatigue Fever Night sweats Chills Loss of appetite Tuberculosis can also affect [mayoclinic.org]

  In March, she was still coughing and thru a Cambodian interpreter, she complained of fatigue, shortness of breath (SOB), and decreased appetite. After about 7 weeks, the cultures taken from the bronchoscopy grew M tb. [renalandurologynews.com]

  Constitutional symptoms such as fever, weight loss, fatigue, and anorexia are less common (, 7 –, 9 ). There is often a long latency period (5–40 years) between initial infection and expression of genitourinary disease (, 9 ). [pubs.rsna.org]

• Flank Mass

  The purpose of this report is to present the case of a patient with renal TB in order to emphasize the importance of this disease. we report the case of a 30-year-old female who presented with fever, cough, diaphoresis and an abdominal right flank mass [ncbi.nlm.nih.gov]

• Abdominal Pain

  Indian J Nephrol 2016;26:149-50 A 32-year-old male presented with right-sided abdominal pain. Physical examination revealed right-sided renal angle tenderness. The temperature was 38.7°C and blood pressure 170/82 mmHg. [indianjnephrol.org]

  Six months later the patient had complaints of abdominal pain and dysuria. New laboratorial tests showed serum urea = 187 mg/dL, creatinine = 8.0 mg/dL, potassium = 6.5 mEq/L. Hemodialysis was then started. [ncbi.nlm.nih.gov]

  Two weeks after the surgery the patient was complaining of diffuse abdominal pain and presented a palpable abdominal mass in the left iliac region. The ultrasound showed a cystic mass, with a mean volume of 987mL. [scielo.br]

  Back, flank and abdominal pain are non-specific symptoms often investigated by General Practitioners using plane film X-ray. [casesjournal.biomedcentral.com]

  Symptoms may also include back, flank, or abdominal pain (, 7 –, 9 ). Constitutional symptoms such as fever, weight loss, fatigue, and anorexia are less common (, 7 –, 9 ). [pubs.rsna.org]

• Left Flank Pain

  Abstract A 74-year-old woman presented with a 3-day history of fever and left flank pain. The imaging study revealed a huge complicated cyst in the left kidney. The cyst had a mass effect to the abdomen. [ncbi.nlm.nih.gov]

• Dysuria

  Six months later the patient had complaints of abdominal pain and dysuria. New laboratorial tests showed serum urea = 187 mg/dL, creatinine = 8.0 mg/dL, potassium = 6.5 mEq/L. Hemodialysis was then started. [ncbi.nlm.nih.gov]

  In the urinary incontinence at the same time there is urgency, dysuria. 2. Hematuria, which is another important symptom of renal tuberculosis incidence rate of about 70%. [tcmwell.com]

  The onset of clinically evident genitourinary tuberculosis is often insidious, with dysuria and gross hematuria being the most common symptoms [6]. [scielo.br]

• Flank Pain

  CONCLUSIONS: While gross hematuria is more prevalent in older patients and male patients, flank pain is more common in female patients. [ncbi.nlm.nih.gov]

  Clinical features are often nonspecific and include: hematuria flank pain constitutional symptoms Diagnosis can be obtained by culturing multiple first-morning-void urine samples, or by histology of imaging guided biopsy or surgical specimens, although [radiopaedia.org]

• Urinary Urgency

  Urinary urgency is relatively uncommon unless the bladder is extensively involved. Patients with GUTB may also present with a painful testicular swelling, perianal sinus, or genital ulcer. [emedicine.medscape.com]

• Urinary Incontinence

  Advanced bladder contracture, capacity is small and up to dozens of daily frequency of urination, and even showed the phenomenon of urinary incontinence. In the urinary incontinence at the same time there is urgency, dysuria. 2. [tcmwell.com]

With a properly obtained patient history and a detailed physical examination, sufficient evidence may be obtained to pursue a diagnosis of renal tuberculosis. As immunosuppression is one of the main risk factors for an infection by M. tuberculosis, patients should be asked about underlying illnesses (for example, human immunodeficiency virus infection, transplantation, dialysis, etc.) [1], but also if they already suffered from tuberculosis, since about 25% of cases were previously diagnosed with pulmonary tuberculosis [4]. After assessing the presence of signs and symptoms that are further evaluated during the physical examination, a full laboratory workup and urinalysis should be performed. In addition to hematuria and proteinuria, sterile pyuria is a hallmark of tuberculosis, in which case more advanced microbiological studies are necessary. Acid-fast staining (by using Ziehl-Neelsen stain) and cultivation of at least three urine samples obtained in the morning on the Lowenstein-Jensen medium are highly successful methods for detecting M. tuberculosis, yielding a positive rate of up to 95% [2] [3] [4]. But as mycobacteria grow very slowly on these media, approximately 6-8 weeks need to pass before a definite diagnosis can be made, which is why more advanced methods that detect bacterial DNA (like PCR) are often used [2]. Imaging procedures (ultrasonography, computed tomography, magnetic resonance imaging, intravenous urography, chest X-rays) are equally important for assessing the status of the kidneys and potentially reveal any pathological lesions [1] [2] [3] [4] [6].

• Nephrolithiasis

  Xanthogranulomatous pyelonephritis (XGPN) is a chronic renal infection typically associated with nephrolithiasis and a non-functioning kidney. Renal tuberculosis is a major cause of morbidity in developing countries. [ncbi.nlm.nih.gov]

  Three other major complications of renal tuberculosis: hypertension (RAS axis mediated) super-infection (12 to 50%) nephrolithiasis (7 to 18%) In 1940, Nesbit and Ratliff reported that hypertension could be cured by the removal of a tuberculous kidney [slideshare.net]

• X-Ray Abnormal

  Chest x-ray abnormalities are found in 52 to 75%. 9 Patients are often unaware of their initial pulmonary infection. A high proportion (50% to 75%) of men with genital TB have radiologic abnormalities in their urinary tracts. [journals.lww.com]

• Pyuria

  Most patients with renal TB have sterile pyuria, which can be accompanied by microscopic hematuria. The diagnosis of urinary tract TB is based on the finding of pyuria in the absence of common bacterial infection. [ncbi.nlm.nih.gov]

  In addition to hematuria and proteinuria, sterile pyuria is a hallmark of tuberculosis, in which case more advanced microbiological studies are necessary. [symptoma.com]

• Granulomatous Tissue

  This usually occurs secondary to abnormal calcitriol production by the granulomatous tissue. [indianjurol.com]

Evidence of ureteric obstruction was obtained in 30 patients (50%)--23 at the time of diagnosis, 6 during treatment and 1 at the time of relapse. Following corticosteroid treatment relief of obstruction was obtained in 72%. [ncbi.nlm.nih.gov]

[…] pyelonephritis Papillary necrosis Medullary sponge kidney Xanthogranulomatous pyelonephritis Treatment Anti-tuberculous drugs Nephrectomy Complications Untreated, end result is autonephrectomy Infertility in females Sinus and fistula tract formation Prognosis [learningradiology.com]

The occurrence of ureteral calcification along with renal calcifications further proves the diagnosis of lobar presentation and generally has unfavorable prognosis. [1], [3] Intravenous urogram is regarded as the investigations of choice that provides [indianjnephrol.org]

[…] 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 ) Treatment and prognosis [radiopaedia.org]

Prognosis Most patients who are treated for TB with the recommended course of antimicrobials recover without relapse. Patients need to take all the medications for the entire 6 to 9 months of therapy. DOT is the preferred strategy. [renalandurologynews.com]

In many countries, tuberculosis is still the main etiologic factor. We report a case of a 40-year-old woman who presented a course of protracted and recurrent episodes over five years of cutaneous lesions on her legs. [ncbi.nlm.nih.gov]

Etiology of spontaneous perirenal hemorrhage: a meta-analysis. J Urol 2002;167:1593-96. [tmj.ro]

Frequency and etiology of gross hematuria in a general pediatric setting. Pediatrics. 1977;59(4):557-61 19. Dhua AK, Borkar N, Ghosh V, Aggarwal SK. Renal tuberculosis in infancy. J Indian Assoc Pediatr Surg. 2011Apr;16(2):69-71 20. [degruyter.com]

Etiology of Urogenital Tuberculosis Causative agent of tuberculosis: Mycobacterium tuberculosis is a 1–2 microns long immobile bacillus. Other features include: acid-resistant, intracellular persistence in phagocytes, doubling time 20 hours. [urology-textbook.com]

Vijaykumar, Sumanth Bhoopal Indian Journal of Surgery. 2012; [VIEW] | [DOI] 4 Etiology and management of genitourinary tuberculosis Aula Abbara, Robert N. Davidson Nature Reviews Urology. 2011; 8(12): 678 [VIEW] | [DOI] [indianjurol.com]

Abstract The epidemiology of renal tuberculosis is characterised by a considerable variation in the frequency and distribution of the infection. [ncbi.nlm.nih.gov]

Haydarnejad H, Ashrafi H. epidemiologic study of tuberculosis in Tabriz, a 10 years study.Ashrafi H, MD Thesis. 1997; Faculty of medicine, Tabriz University of medical science. Page 17 (thesis is in Persian) 5. Nourizadeh D, Madaen K, Gaderian N. [sjkdt.org]

Epidemiology of urogenital tuberculosis worldwide. Int J Urol. 2008;15(9):827-32 5. Rai A, Pahwa H, Jain V, Misra S. Management of Genito-Urinary Tuberculosis. The Internet Journal of Surgery 2010;23(1). DOI: 10.5580/173a 6. [degruyter.com]

Tuberculosis epidemiology in Germany: The incidence and mortality of tuberculosis in Germany is declining. Figures from 2010: 4330 new cases (1999: 9800 new cases). Incidence 5/100000. Mortality is 0.2 /100000, of which 2/3 are older than 65 years. [urology-textbook.com]

Epidemiology of urogenital tuberculosis worldwide. International Journal of Urology 2008; 15: 827-832. In article CrossRef [5] Gow JG. Genitourinary tuberculosis. In: Walsh PC, Retik AB, Vaughan ED, Wein AJ (eds). Campbell’s urology. V.1, 7a edn. W. [pubs.sciepub.com]

This article gives review of pathophysiology and computed tomography features of Renal TB. This is a preview of a remote PDF: https://link.springer.com/content/pdf/10.1007%2Fs40134-014-0069-5.pdf Ashwini Sankhe, Anagha R. Joshi. [paperity.org]

Risk factors for active tuberculosis: Immigrants Alcoholism Old age AIDS Diabetes mellitus Steroid therapy Intravenous drug abuse Smoking Lung diseases: Silicosis, COPD Malnutrition Malignant diseases Gastric resection Crowding, e.g. prisons Pathophysiology [urology-textbook.com]

Pathophysiology Infection with M tb produces tuberculosis. The most common site involved is the lung, but tuberculosis may involve any organ, may be disseminated or may be asymptomatic. The pathogenesis of tuberculosis is a two-stage process. [renalandurologynews.com]

The epidemiology of TB, both pulmonary and extrapulmonary (especially genitourinary TB [GUTB]), has been covered in part I of this article, with a detailed description of the spread and pathophysiology of primary and reactivated TB. [ijri.org]

In countries in which tuberculosis is endemic, it is important to have a high index of suspicion for tuberculosis in patients with renal calcifications in order to facilitate treatment and to prevent autonephrectomy. [nejm.org]

Factors concerned with prevention in high risk groups are discussed. [ncbi.nlm.nih.gov]

Centers for Disease Control and Prevention. (2014 February 7, Updated.) Treatment for Latent TB Infection. Available online at http://www.cdc.gov/tb/topic/treatment/ltbi.htm. Accessed January 2016. Centers for Disease Control and Prevention. [labtestsonline.it]

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