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.

• Splenomegaly

  […] body, for example, features of abdominal TB such as ascites (especially with septations), omental infiltration, peritoneal thickening, mesenteric involvement, bowel wall thickening, enlarged lymph nodes (especially those with necrosis) [Figure 13], splenomegaly [ijri.org]

• Constitutional Symptom

  RESULTS: The most common local presentations were lower urinary tract symptoms (65.2%), flank pain (37.9%), and gross hematuria (26.3%). Constitutional symptoms were also observed in 38.9% of the patients. [ncbi.nlm.nih.gov]

  There are no specific clinical symptoms associated with renal tuberculosis. The constitutional symptoms like low grade fever, weight loss, anorexia commonly seen with pulmonary TB are not usually seen with renal TB. [paperity.org]

  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]

  Clinical presentation is nonspecific and can include hematuria, flank pain, dysuria, and/or constitutional symptoms. Positive urine cultures or a histopathological exam of surgical or biopsy specimens establishes a definitive diagnosis. [radiologytoday.net]

• 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]

  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]

  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]

  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]

• Falling

  Abstract Because Goldblatt 1 could, by removing the ischemic kidney in his experimental hypertensive dogs, cause a fall of blood pressure to normal, the possible clinical application of his results to cases of essential hypertension in man aroused considerable [annals.org]

  After falling 06 months an ultrasound does not objectified tumor recurrence. [webmedcentral.com]

  Gueye SM, Ba M, Sylla C, Ndoye AK, Fall PA, Diaw JJ, et al. [Epididymal manifestations of urogenital tuberculosis]. Prog Urol. 1998;8(2):240-3. [ Links ] 38. Vasanthi R, Ramesh V. Tuberculous infection of the male genitalia. [scielo.org.co]

  Results of blood sedimentation rate (ESR) showed that despite proven tuberculous infection 25 out of 56 investigated (44.7%) showed blood sedimentation rate within 20 mm fall after first hour (Table VI). [jpma.org.pk]

  Some patients may progress to end-stage renal failure-if anatomic distortion is advanced and bilateral and leads to a fall in glomerular filtration. 11 TREATMENT Significant advances have been made in the treatment of urinary TB with a reported mortality [journals.lww.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]

  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]

  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]

• Pathologist

  Two pathologists assessed the kidney histology. We correlated the LAM-assay results and the histology findings. RESULTS: Of the 13/36 (36%) patients with a positive urinary LAM ELISA and/or LFA, 8/13 (62%) had renal TB. [ncbi.nlm.nih.gov]

  Two pathologists assessed the kidney histology. We correlated the LAM-assay results and the histology findings.RESULTS: Of the 13/36 (36%) patients with a positive urinary LAM ELISA and/or LFA, 8/13 (62%) had renal TB. [chs.mak.ac.ug]

  Hematotoxylin and eosin (H&E) slides were made for each tissue section and read by 2 experienced pathologists. In case of discrepancy, discussion between the two pathologists would provide consensus. [journals.plos.org]

  TB of the prostate is uncommon, and in many cases the pathologist diagnoses it incidentally after a TURP. TB of the penis and of the urethra are also very unusual manifestations. Primary TB of the penis appears as a superficial ulcer of the glans. [ispub.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]

  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]

  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]

• Fear

  Cystoscopy under general anaesthesia with adequate muscle relaxation helps to visualize the mucosal lesions,golf hole uretericorifice.or the reflux of toothpaste like caseous material Biopsy during acute stage is avoided for fear of dissemination of T.B [slideshare.net]

• 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]

• Microscopic Hematuria

  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]

  Microscopic hematuria is present in up to 50% patients. Ureteral colic is uncommon and occurs only if a small flake of calcification or a clot passes down the ureter. Recurrent cystitis is also a warning sign of urinary TB. [ispub.com]

  Some patients are asymptomatic, and pyuria and/or microscopic hematuria are found incidentally. These two abnormalities are present in more than 90% of cases [7]. [scielo.br]

• 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]

• Small Kidney

  Coronal reformatted non-enhanced CT scan of the abdomen and pelvis demonstrates a small, left kidney containing globular calcifications (white circle) pathognomonic for renal tuberculosis. [learningradiology.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]

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

An Over-view on Epidemiology of Tuberculosis. Mymensingh Med J. 2019;28(1):259-66. [ Links ] 13. Figueiredo AA, Lucon AM, Junior RF, Srougi M. Epidemiology of urogenital tuberculosis worldwide. Int J Urol. 2008;15(9):827-32. [ Links ] 14. [scielo.org.co]

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]

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]

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]

The end results are organ destruction, renal function loss, and diffuse calcifications.17 The pathophysiology of renal TB is shown in Figure 4. Pathophysiology of renal tuberculosis. [ncbi.nlm.nih.gov]

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]

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]

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]

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