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

  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]

  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]

  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]

• 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]

• Painful Cough

  She denied fever, chills, night sweats, flank or abdominal pain, cough, hemoptysis, or weight loss. Her husband had been treated for pulmonary TB in 1968. She had a positive TB skin test (purified protein derivative) in 1987, without treatment. [journals.lww.com]

• Abdominal Pain

  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]

  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]

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

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

  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]

• Subcutaneous Nodule

  Erythema induratum of Bazin is a disease that usually affects women, in whom erythematous subcutaneous nodules and plaques appear on the posterior part of the lower extremities, some of which ulcerate. [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]

• Bladder Pain

  There are silent forms with few symptoms of spread and without very great bladder pain; nevertheless these forms can be very destructive, and even on first presentation may show a destroyed kidney. [ncbi.nlm.nih.gov]

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]

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3. de Oliveira JL, da Silva Junior GB, Daher Ede F.
   Tuberculosis-associated chronic kidney disease. Am J Trop Med Hyg. 2011;84:843–844.
4. Gibson MS, Puckett ML, Shelly ME. Renal tuberculosis. Radiographics. 2004;24(1):251-256.
5. Daher Ede F, Silva Júnior GB, Damasceno RT, et al. End-stage renal disease due to delayed diagnosis of renal tuberculosis: a fatal case report. Braz J Infect Dis. 2007;11:169–171.
6. Jung YY, Kim JK, Cho KS. Genitourinary tuberculosis: comprehensive cross-sectional imaging. AJR Am J Roentgenol. 2005;184(1):143-150.