View
221
Download
0
Category
Preview:
Citation preview
8/2/2019 Seminar Renaltb 110713085451 Phpapp02
1/57
Click to edit Master subtitle style
.
GenitourinaryTuberculosis
8/2/2019 Seminar Renaltb 110713085451 Phpapp02
2/57
Etiology
Genus Mycobacterium
Weakly gram+ive,Acid fast
- i i i i i i
8/2/2019 Seminar Renaltb 110713085451 Phpapp02
3/57
Disease of young to middle-aged adults as genitourinarydisease occurs 5 to20 years after primary pulmonaryinfection
M/F ratio= 5:3(In contrast to other forms of non-pulmonary TB)
Approximately 20-30% of extra-pulmonaryinfection(second most frequent form of non pulmonaryTB)
Seen in approximately 4% to 8% of non-HIV infected
8/2/2019 Seminar Renaltb 110713085451 Phpapp02
4/57
Hematogenous spread
Rarely primary one
Transplant recipient
8/2/2019 Seminar Renaltb 110713085451 Phpapp02
5/57
25% of the patients with genitourinary tuberculosishave a history of diagnosed tuberculosis.
In an additional 25% to 50% of patients, changescompatible with old pulmonary tuberculosis can befound on chest x-ray films.
8/2/2019 Seminar Renaltb 110713085451 Phpapp02
6/57
The small silent renal microgranulomas resulting fromsilent haematogenous dissemination are typically foundbilaterally in the renal cortex
These cortical granulomas remain dormant until unknownfactors permit the bacilli to proliferate.
If enlarging granuloma rupture, delivers organisms into theproximal tubule.
Pathogenesis
caseation fibrosis
8/2/2019 Seminar Renaltb 110713085451 Phpapp02
7/57
Bacilli in the nephron are trapped at the level of
loop of henle,where they multiply and survive well
possibly on account of impaired phagocytosis in
the hypertonic environment.
Clinically important renal tuberculosis,
therefore, is usually initially localized to themedulla and is usually unilateral.
8/2/2019 Seminar Renaltb 110713085451 Phpapp02
8/57
Progressive destruction with cavity formation
Papillary necrosis
tuberculous pyonephrosis (caseocavernous renaltuberculosis) are common in advanced disease.
Communication with the collecting system usually isresponsible for the spread of bacilli to the renal pelvis,
ureter & bladder
8/2/2019 Seminar Renaltb 110713085451 Phpapp02
9/57
Fibrosis accompanies the granulomatous process
infundibular stricturesand renal pelvic kinking
obstructive uropathy
The end-stage kidney is nonfunctional
8/2/2019 Seminar Renaltb 110713085451 Phpapp02
10/57
URETER Results inUlceration,fibrosis,stricture,calcification
Most common site is ureterovesicalf/b pelviureteric
BLADDER--Involvament starts from uretericorifice , which contracts..then inflammationspreads deep.fibrosis results inSmall,contracted with stiff wall bladder-THIMBLE BLADDER
8/2/2019 Seminar Renaltb 110713085451 Phpapp02
11/57
Genital TBAlways by hematogenous spread
FemaleFallopian tube most common,50%
involve uterus
MaleProstate,seminal vesicles,epididymis
Rarely involve urethraUrethralstricture,periurehral abscess or fistulaformation results
8/2/2019 Seminar Renaltb 110713085451 Phpapp02
12/57
Pathology: Gross
Renal tuberculosis. Photograph of a cut gross specimen shows
multiple, predominantly peripheral, white tuberculous
granulomas throughout the kidney.
8/2/2019 Seminar Renaltb 110713085451 Phpapp02
13/57
Photographs of a cut gross specimen show the earlynecrosis of the medullary tip (black spot in a). Once
devitalized, the papilla sloughs off, leaving a defect
(cavity in b)
8/2/2019 Seminar Renaltb 110713085451 Phpapp02
14/57
Calcification in advanced lesions is common and may be focalor generalized, which produces a putty or cement kidney.
8/2/2019 Seminar Renaltb 110713085451 Phpapp02
15/57
Caseating granuloma
Bilateral microscopic renalinvolvement is the rule.
Pathology: Microscopic
8/2/2019 Seminar Renaltb 110713085451 Phpapp02
16/57
Insidious modeof presentation, with approximately 20%of cases diagnosed unexpectedly at operation or autopsy.
A high index of suspicion enables early diagnosis
One measure of the frequently occult nature of urinarytract tuberculosis comes from Lattimer's report in which18 of 25 physicians with renal tuberculosis beingdiagnosed only after far-advanced cavitary disease had
developed.
Clinical Features
8/2/2019 Seminar Renaltb 110713085451 Phpapp02
17/57
close contact with sputum positive individualP/H/O pulonary TB,
immunosuppression,
HIV infection,diabetes mellitus
renal failure
elderly
patients with TB elsewhere
Risk factors
8/2/2019 Seminar Renaltb 110713085451 Phpapp02
18/57
Approximately 75% of patients present with symptomssuggesting urinary tract inflammation.
-Dysuria
-Mild or moderately severe back or flank pain
-Recurrent bouts of painless gross hematuria-10%
-Nocturia (due to conc. Defect)
-Pyuria (esp. episodic)
-
8/2/2019 Seminar Renaltb 110713085451 Phpapp02
19/57
Bladder symptoms in advanced cases (urgency, frequency)
Paucity of constitutional symptoms usually associated withtuberculosis such as fever, weight loss, night sweats, andanorexia.
Constitutional symptoms should lead to a search for otherfoci of tuberculosis
8/2/2019 Seminar Renaltb 110713085451 Phpapp02
20/57
Hence, it is important that the diagnosis is
considered in all patients with equal-sized smooth
kidneys without a clear-cut renal diagnosis,especially in high-risk groups
In such patients renal biopsy should always be
considered.
Mallinson et al. Quarterly Journal of Medicine1981
Tubercular interstitial
nephritis
8/2/2019 Seminar Renaltb 110713085451 Phpapp02
21/57
Glomerular Diseases
Rare association with
-dense deposit disease
-Mesangio-capillary glomerulonephritis
AmyloidosisChronic tuberculosis sometimes leads to amyloidosis and
in India is a not uncommon cause of renal amyloid and renal
failure
8/2/2019 Seminar Renaltb 110713085451 Phpapp02
22/57
Three other major complications of renal tuberculosis:
hypertension (RAS axis mediated)
super-infection (12 to 50%)
nephrolithiasis (7 to 18%).
8/2/2019 Seminar Renaltb 110713085451 Phpapp02
23/57
Female--Infertility,menstrualdisturbances,vaginal discharge,pelvic pain
Male--Scrotal pain orswelling,haemospermia,superficial penileulceration
Diagnosis
8/2/2019 Seminar Renaltb 110713085451 Phpapp02
24/57
DiagnosisUrine analysis
Essentially every patient with established urinary tract tuberculosis has an
abnormal urinalysis with pyuria, hematuria, or both.
20%OF GUTB pt. hv secondary becterial
infection
50% having microscopic hematuria
Sterile pyuria
the old clinical teaching that the asymptomatic patient with pyuria, particularly
with an acid urine and a urine culture that fails to reveal conventional bacterial
pathogens, must be considered as having tuberculosis until proved otherwiseremains true today
Another indicator is failure of the patient's symptoms to respond toconventional antibacterial treatment
8/2/2019 Seminar Renaltb 110713085451 Phpapp02
25/57
Early-morning urine specimens are preferred
Sterile container
three to five daily specimens
Preferably immediate examination, if delay unavoidable
sample must be refrigerated, not freezed.
8/2/2019 Seminar Renaltb 110713085451 Phpapp02
26/57
concentrated by centrifugation.
Smears prepared from sediment
Z-N staining.
Problem of E.M.s(Mycobacteria Smegmatis)
G.U.T.B. should never be diagnosed solely on the basis
8/2/2019 Seminar Renaltb 110713085451 Phpapp02
27/57
Gold standard
positive in 80% to 90% of cases
Decontamination of sediment.
main problems:
-COST
-AVAILABILITY
-DELAYS
Culture
8/2/2019 Seminar Renaltb 110713085451 Phpapp02
28/57
8/2/2019 Seminar Renaltb 110713085451 Phpapp02
29/57
High dose IVU traditional gold standard CT new standard
Pyelography (ante/retrograde) limited use
Plain radiographs important
CXR,spine X-Ray,X-Ray KUB
US limited value
Nuclear Perfusion Scan function
MRI,Arteriography little application Anterograde pyelography
Imaging
8/2/2019 Seminar Renaltb 110713085451 Phpapp02
30/57
X-Rays
Plain films of the abdomen-
-genitourinary calcifications (present in up to 50%) as
well as other extrapulmonary foci of mycobacterial disease
(vertebral, mesenteric lymph node, adrenal glands) may bepresent (approximately 10%)
-MULTIPAL ILL-DEFINED,IRREGULAR CORTICAL
CALCIFICATION
Chest radiographs show evidence of tuberculosis in 50%
Radiology
8/2/2019 Seminar Renaltb 110713085451 Phpapp02
31/57
Plain radiograph of the abdomen demonstrates extensivecalcification in the left kidney, which was nonfunctional (the puttykidney), consistent with autonephrectomy from tuberculosis.
8/2/2019 Seminar Renaltb 110713085451 Phpapp02
32/57
Sonogram of left kidney shows 1.5-cm hypoechoic nodule(arrowhead) in cortex
USG
-initial investigation of choice
Cavities
Obstruction
Early findings may be missed
I t l h & CT
8/2/2019 Seminar Renaltb 110713085451 Phpapp02
33/57
Intravenous urography - most useful to provide images
of detailed anatomy and FUNCTION to show thecommonly occurring multiple lesions
Renal calcification is common (24-44%)
Cortical scarring
papillae (moth-eaten) irregular due to inflammation and
Intravenous pyelography & CT urogramfindings
8/2/2019 Seminar Renaltb 110713085451 Phpapp02
34/57
Hicked-up pelvis (Kerr kink sign)
Infundibular strictures
Hydrocalyces without dilatation of renal pelvis, or
Hydronephrosis
"Putty kidney"
Autonephrectomy small, shrunken kidney with dystrophic
calcification
8/2/2019 Seminar Renaltb 110713085451 Phpapp02
35/57
When ureters are involved, usually the upper or lower third
(more common)
Beading (sawtooth ureter)Corkscrew ureter
Pipe stem ureter
Bladder involvement rarely leads to calcification of wall
(think schistosomiasis)Reflux, thickening of bladder wall (thimble bladder),
fistula formation
8/2/2019 Seminar Renaltb 110713085451 Phpapp02
36/57
IVP of 32-year-old woman. A, left renal parenchymal mass (arrows) and lefthydroureter due to left distal ureteral stricture (arrowheads). B, magnificationof left kidney shows irregular caliceal contour as moth-eaten appearance(arrows) of upper calix and multiple cavities (arrowheads) of lower pole.
8/2/2019 Seminar Renaltb 110713085451 Phpapp02
37/57
Genitourinary tract tuberculosis. Lobar calcification in alarge destroyed right kidney in a patient with renaltuberculosis. Note the involvement of the right ureter.
8/2/2019 Seminar Renaltb 110713085451 Phpapp02
38/57
IVP film-The lower end of the right ureter demonstrates an irregularcaliber with an irregular stricture at the right vesico-uretericjunction. Note the asymmetric contraction of the urinary bladder,
with marked irregularity due to edema and ulceration.
8/2/2019 Seminar Renaltb 110713085451 Phpapp02
39/57
Genitourinary tract tuberculosis. Intravenous urography series in aman with renal tuberculosis shows marked irregularity of thebladder lumen due to mucosal edema and ulceration
8/2/2019 Seminar Renaltb 110713085451 Phpapp02
40/57
8/2/2019 Seminar Renaltb 110713085451 Phpapp02
41/57
Renal Tuberculosis. Coronal reformatted non-enhanced CTscan of the abdomen and pelvis demonstrates a small, leftkidney containing globular calcifications (white circle)pathognomonic for renal tuberculosis.
PUTTY
8/2/2019 Seminar Renaltb 110713085451 Phpapp02
42/57
Click icon to add picture
PUTTYKIDNE
Y.
8/2/2019 Seminar Renaltb 110713085451 Phpapp02
43/57
A, CT urogram shows severe nonuniform caliectasis and multifocal strictures (arrowheads)involving renal pelvis and ureter.Calcification (arrow) is noted in left distal ureter.
B, Contrast-enhanced CT scan shows wall thickening and enhancement of left ureter
(arrowhead).
8/2/2019 Seminar Renaltb 110713085451 Phpapp02
44/57
May be normal in patients with early genitourinarytuberculosis.
Calcification may occur in patients with Diabetes mellitus
and schistosomiasis. Brucellosis also may mimic tuberculosis.
A congenital megacalyx and focal papillary necrosis may
mimic renal tuberculosis radiologically.
Limitations-
8/2/2019 Seminar Renaltb 110713085451 Phpapp02
45/57
Genitourinary tract tuberculosis. Lateral view of the abdomen in apatient with schistosomiasis shows tubular calcification of the
ureters in contrast to the speckled calcification in tuberculosis.
8/2/2019 Seminar Renaltb 110713085451 Phpapp02
46/57
Radiograph of the pelvis in a patient with schistosomiasis shows fine linear calcifications of thebladder wall with normal volume. In tuberculosis, the bladder is contracted and demonstrates
speckled calcification
8/2/2019 Seminar Renaltb 110713085451 Phpapp02
47/57
Cystoscopy under general anaesthesia withadequate muscle relaxation helps to visualize the
mucosal lesions,golf hole ureteric orifice.or the
reflux of toothpaste like caseous materialBiopsy during acute stage is avoided for fear of
dissemination of T.B
Aspirated pus and caseous material generally contain
few viable mycobacteria so it is more rewarding toexamine biopsies of the surrounding tissue.
Cystoscopy
8/2/2019 Seminar Renaltb 110713085451 Phpapp02
48/57
Two goals
Clinical Management
conservation of tissue
and functionantimycobacterial cure.
8/2/2019 Seminar Renaltb 110713085451 Phpapp02
49/57
It is a common practice for clinicians to treat GUTB for
periods longer than six months.
DOTSis the most effective way
Standard Category I regimen is effective for the treatmentof patients with GUTB
Antimicrobial cure
RNTCP- DOTS Therapy
8/2/2019 Seminar Renaltb 110713085451 Phpapp02
50/57
Genito-urinary T.B. -- Cat I
(HRZE)2 + (HR)4
Drug Intr. Dose
Isoniazid 10mg/kg
Rifampicin 10mg/kg
Pyrizinamide 35mg/kg
Ethambutol 25mg/kg
Streptomycin 15mg/kg daily
Streptomycin- max. dose 750 mg in pts.
8/2/2019 Seminar Renaltb 110713085451 Phpapp02
51/57
INHRifampicin no adjustment
Pyrazinamide
Drug Cr. Clearance Dose interval
Ethambutol 10-50 ml/min 24-36 hrs
8/2/2019 Seminar Renaltb 110713085451 Phpapp02
52/57
RNTCP guidelines- silent.
After 2 month of therapy-
3 urine cultures
If negative- continue therapy
At the end of therapy
3 consecutive negative samples
Repeated after 3 months and at 1 year.
Treatment monitoring
8/2/2019 Seminar Renaltb 110713085451 Phpapp02
53/57
IVP
-at the end of 2 months
-and at the completion of Tt.
In case of renal calcification- yearly 3 urine examinationsup to 10 years.
Treatment monitoring
What is the role of
8/2/2019 Seminar Renaltb 110713085451 Phpapp02
54/57
Another area of controversy in the treatment of GUTB isthe utility of corticosteroids in the prevention ofcomplications such as ureteric stricture/fibrosis
Lack of RCTs on this issue
it seems unlikely that corticosteroids would be able toreduce the development of complications such as uretericobstruction in patients with GUTB. This issue is worth
investigating
corticosteroids?
8/2/2019 Seminar Renaltb 110713085451 Phpapp02
55/57
Atleast 4 weeks of chemotherapy required before
surgery exccept in early stenting for ureteral strictures
Today the primary form of surgical intervention is in therelief of strictures, particularly those of the ureters,which can result from the scarring process.
Thus, ureteral dilatations, ureteral reimplantations, and insome cases, relief of intrarenal obstruction to urine flow
are important aspects of the modern function-conservinga roach to urinar tract tuberculosis
Surgical Management
8/2/2019 Seminar Renaltb 110713085451 Phpapp02
56/57
Less commonly, patients whose bladders have been badly
scarred by the tuberculosis process have such poor
bladder function that bladder augmentation or even urinary
diversion may be necessary to deal with unbearable urinary
frequency, inadequate emptying, or both.
8/2/2019 Seminar Renaltb 110713085451 Phpapp02
57/57
Rare event now a days
End-stage tuberculous kidneys with complications
- bacterial sepsis-Hemorrhage
-Intractable pain
-Newly developed severe hypertension-Inability to sterilize the urine because of
patient unreliability
-Coexiting carcinoma
nephrectomy
Recommended