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Case Report | Discussion

Case report:

A 55-year-old lady a known case of genitourinary tuberculosis presented with fever and pain in the abdomen, tenderness, and pyuria.

An augmentation cystoplasty had done in 1985.. A plain radiograph of the abdomen was taken. The frontal view is shown (Fig 1)

Note the presence of an 8x4cm calcified, lobulated, reniform mass lesion lateral to L1 and L2 vertebral bodies in the midclavicular line on the left side with calcification of the upper 1/3^rd of the ureter. As the patient is a known case of GU Kochs the findings are suggestive of a putty kidney. A micturating cystourethrogram was done (Fig 2)

The urinary bladder is irregular and of moderate capacity. The shape of the bladder is consistent with findings following augmentation cystoplasty. The right kidney shows changes of hydronephrosis with moderate dilatation and tortousity of the ureter. The findings are suggestive of grade IV vesico-ureteral reflux

 

Discussion

Tuberculosis of the urinary tract continues to be an important clinical problem due to its non-specific clinical presentation and a variable radiographic appearance.

Incidence:

- Predominant between 2^nd and 4^th decades of life
- Incidence is low in children and in the 5^th and 6^th decades.
- Men are more frequently affected than women.
- More than half of the patients have some lung abnormality indicative of past pulmonary tuberculosis

Pathogenesis:
Mycobacterium tuberculosis is the causative organism of urinary tract tuberculosis. Discharge of M tuberculosis from an active source of infection leads to the formation of miliary tuberculomas in the kidneys.Few tubercles regress while some enlarge and rupture into a nephron producing tuberculous bacilluria without a radiographic lesion.

The granulomas affect the medulla and the papillae and coalesce to form a cavity communicating with the pelvicalyceal system. There is resultant destruction of the parenchyma with localized hydrocalicosis due to stricture of the infundibular or the calyceal neck. Finally, autonephrectomy of the kidney leads to a nonfunctioning calcified kidney.The involvement of the ureter occurs due to the passage of infected urine through the ureter or refluxly from an infected bladder leading to mucosal and wall ulceration, fibrosis, stricture and calcification .

Bladder cystitis leads to a small capacity bladder called as a thimble bladder .

Imaging studies
Each imaging modality has its own contribution

Plain films: These are done to evaluate lung lesions and abdominal-calcification of adrenals, lymphnodes. And in the renal areas.

Urograms: Intravenous urography is the modality of choice as the visualization of the pelvicalyceal system helps in the early detection of renal tuberculosis

Ultrasonography: Focal renal lesion with an echogenic border and central area of low echogenicity. Calcification, focal area of atelectasis Perinephric abscess.

CT: This helps in the detection of fine calcifications and presence of disease in the adjacent genital tract.

Prognosis: A major change in the clinical course of the disease has taken place with the introduction of effective anti-tuberculous chemotherapy and newer modalities of investigation .