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RG f Volume 24 ● Number 1 Gibson et al 251

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Renal Tuberculosis1
Michael S. Gibson, MD ● Michael L. Puckett, MD ● Mark E. Shelly, MD

of levofloxacin and one course of nitrofurantoin.


Contrast material– enhanced computed tomogra-
phy (CT) of the abdomen was performed for fur-
ther evaluation of the persistent hematuria and
pyuria. Mycobacterium tuberculosis was isolated at
acid-fast bacteria urine culture. The patient was
started on a multidrug therapeutic regimen,
which was well tolerated initially. During the
course of treatment, mild hepatotoxicity devel-
oped, as evidenced by elevated liver transaminase
levels.

Imaging Findings
Unenhanced helical CT of the abdomen demon-
strated large, globular high-attenuation areas in
Figure 1. Unenhanced CT scan shows two large cal- the upper pole of the right kidney (Fig 1). Con-
cifications in the medial upper pole of the right kidney trast-enhanced nephrographic-phase CT showed
(arrows). cortical thinning with markedly dilated calices
that appeared to communicate with the globular
high-attenuation areas (Fig 2a). The right ureter
History was thickened and demonstrated abnormal mural
A 55-year-old woman presented with a 3-month enhancement (Fig 2b). The left kidney was unre-
history of recurrent episodes of dysuria and gross markable. Delayed excretory-phase CT revealed
hematuria. The patient had a remote history of infundibular narrowing as well as long-segment
positive purified protein derivative skin test re- mural thickening, luminal narrowing, and irregu-
sults but had never received treatment for tuber- larity of the right ureter (Fig 3).
culosis. Urinalysis revealed too-numerous-to-
count white and red blood cells but no growth on
multiple urine cultures. The patient showed mini-
mal symptomatic improvement after two courses

Index terms: Kidney, diseases, 81.23 ● Tuberculosis, genitourinary, 81.23

RadioGraphics 2004; 24:251–256 ● Published online 10.1148/rg.241035071


1From the Department of Radiology, Naval Medical Center San Diego, 34800 Bob Wilson Dr, Bldg 1, 2nd Fl, San Diego, CA 92134. Received
March 17, 2003; revision requested April 16 and received June 16; accepted June 16. Address correspondence to M.S.G. (e-mail:
drgibby7@cox.net).
©
RSNA, 2004
252 January-February 2004 RG f Volume 24 ● Number 1

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Figures 2, 3. (2a) Contrast-enhanced nephrographic-phase CT scan shows dilated calices and thin-
ning of the renal cortex (arrow). (2b) Magnified view from a contrast-enhanced nephrographic-phase
CT scan obtained caudad to a shows mural enhancement and thickening of the proximal ureter (arrow).
(3a) Contrast-enhanced excretory-phase CT scan shows dilated calices and narrowing of the infundibula
(arrowheads). (3b) Contrast-enhanced excretory-phase CT scan obtained at the level of the midureter
shows circumferential ureteral wall thickening (arrow). The left ureter is normal (arrowhead).

Retrograde ureteropyelography showed an Pathologic Evaluation


atrophic right kidney with diffuse caliceal dilata- A laparoscopic right nephroureterectomy was
tion, papillary necrosis, and infundibular narrow- performed with the goal of shortening the dura-
ing (Fig 4a). Mucosal irregularities were present tion of required medical therapy. At macroscopic
along the length of the rigid, straightened, stem- examination, the gross pathologic specimen had a
like right ureter (Fig 4b). multinodular yellow-gray surface. Bivalving of the
Nuclear scintigraphy of the kidney with tech- kidney revealed a 2.5 ⫻ 2.5-cm area of caseous
netium-99m mercaptoacetyltriglycine revealed necrosis in the upper pole (Fig 5), accounting for
only 7% relative function in the atrophic right the CT finding of globular areas of increased
kidney. attenuation. The calices were dilated, a finding
that corresponded to the findings at both CT and
retrograde ureteropyelography.
RG f Volume 24 ● Number 1 Gibson et al 253

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Figure 4. (a) Retrograde ureteropyelogram shows globular calcific areas of increased


opacity in the medial upper pole of the right kidney (arrowheads). The calices are markedly
enlarged with ill-defined margins (white arrows). Small, irregular collections of extracaliceal
contrast material are also present (black arrows). (b) Magnified view from a retrograde ure-
teropyelogram of the right ureter shows mucosal irregularities and erosions (arrowheads).

Figure 6. Low-power photomicrograph (original


magnification, ⫻10; hematoxylin-eosin stain) shows
focal caseating granulomas (arrows) and sheets of
Figure 5. Photograph of the bivalved chronic interstitial inflammation (arrowhead).
resected specimen shows two foci of case-
ous necrosis in the upper pole (arrows).
findings at special staining for acid-fast organisms
and fungi were negative, the patient’s history of
Histologic examination showed caseating positive acid-fast bacteria urine culture coupled
granulomatous inflammation and chronic inter- with the presence of caseating granulomatous in-
stitial inflammation with focal thyroidization of flammation led to a diagnosis of renal tuberculo-
the cortical tubules and associated focal segmen- sis.
tal glomerular sclerosis (Fig 6), findings that are
consistent with chronic pyelonephritis. Although
254 January-February 2004 RG f Volume 24 ● Number 1

RadioGraphics Discussion gional spread of the bacilli into the renal pelvis,
Tuberculosis remains the most common world- ureters, urinary bladder, and accessory genital
wide cause of mortality from infectious disease. organs. The host’s healing response induces fi-
The World Health Organization estimates that 2 brosis, calcium deposition, and stricture forma-
million people die from tuberculosis each year, tion, which may contribute significantly to ob-
with an additional 6 million people developing struction and progressive renal dysfunction (4).
active disease. Approximately one-third of the Despite hematogenous seeding of both kidneys,
world’s population is believed to harbor latent clinically significant disease is usually limited to
infection with M tuberculosis. Although over 90% one side (5).
of cases occur in developing countries, approxi- Patients with genitourinary tuberculosis typi-
mately 15 million individuals in the United States cally have local symptoms including frequent
are infected (1). voiding and dysuria. Hematuria can be either mi-
The genitourinary system is one of the most croscopic or macroscopic. Symptoms may also
common sites of involvement by extrapulmonary include back, flank, or abdominal pain (7–9).
tuberculosis, accounting for 15%–20% of infec- Constitutional symptoms such as fever, weight
tions outside the lungs (1,2). Approximately loss, fatigue, and anorexia are less common (7–9).
4%– 8% of patients with pulmonary tuberculosis There is often a long latency period (5– 40 years)
will develop clinically significant genitourinary between initial infection and expression of genito-
infection (3,4). About 25% of patients who urinary disease (9). Laboratory abnormalities in-
present with tuberculous genitourinary disease clude pyuria, proteinuria, and hematuria (9).
have a known history of prior pulmonary tubercu- Standard urine cultures can be normal. Further-
losis; an additional 25%–50% of patients will more, the presence of routine urinary tract patho-
have radiographic evidence of prior subclinical gens can delay the diagnosis of coexistent tuber-
pulmonary infection (4). culosis. To evaluate for genitourinary tuberculo-
Tuberculosis of the kidney results from hema- sis, at least three first-morning-void urine samples
togenous seeding of M tuberculosis in the glomeru- should be collected for acid-fast staining and my-
lar and peritubular capillary bed from a pulmo- cobacterial cultures. First-morning-void speci-
nary site of primary infection (3–5). Small granu- mens are preferred over 24-hour urine collections
lomas form in the renal cortex bilaterally, adjacent because mycobacterial viability decreases with
to the glomeruli. A high rate of perfusion and fa- prolonged exposure to acid urine (4). M tuberculo-
vorable oxygen tension increase the likelihood of sis is isolated from the urine in 80%–95% of pa-
bacilli proliferating in this location (4). In patients tients with genitourinary tuberculosis (8,9). Puri-
with intact cellular immunity, there is inhibition fied protein derivative skin test results will be
of bacterial duplication with confinement of the positive in nearly all patients but clearly are not
disease process to the cortex (6). Multiple bilat- specific for genitourinary involvement.
eral cortical granulomas can remain asymptom- Imaging findings can support the diagnosis of
atic and dormant for decades (3–5). In some pa- genitourinary tuberculosis, although cultures or
tients, breakdown of host defense mechanisms histologic analysis is required for definitive diag-
leads to reactivation of the cortical granulomas nosis. Renal calcifications are a common manifes-
with enlargement and coalescence (4). Capillary tation of tuberculosis at conventional radiogra-
rupture results in delivery of organisms to the phy, occurring in 24%– 44% of patients (10).
proximal tubule and loop of Henle with eventual Extensive parenchymal calcification in a nonfunc-
development of enlarging, caseating granulomas tioning, autonephrectomized kidney (putty kid-
and papillary necrosis (4). Granuloma formation, ney) is characteristic of end-stage tuberculosis
caseous necrosis, and cavitation are stages of pro- (11). Calcifications may also be amorphous,
gressive infection, which can eventually destroy granular, or curvilinear, typically within the renal
the entire kidney. Communication of the granulo- parenchyma (11,12). Focal globular calcification
mas with the collecting system can lead to re- involving an entire renal lobe is frequently associ-
ated with a granulomatous mass (10). Triangular
ringlike calcifications within the collecting system
are characteristic of papillary necrosis (13). Other
RG f Volume 24 ● Number 1 Gibson et al 255

RadioGraphics extrapulmonary manifestations of mycobacterial CT finding and may be either focal or global (6).
disease, such as mesenteric lymph node and ad- Parenchymal scarring is readily apparent at CT.
renal calcifications, as well as spinal abnormali- Fibrotic strictures of the infundibula, renal pelvis,
ties, may be visible on conventional radiographs. and ureters may be seen at contrast-enhanced CT
These additional findings can lend support to the and are highly suggestive of tuberculosis. CT is
diagnosis of renal tuberculosis (4). not as sensitive as excretory urography in the de-
Intravenous urography can show a broad range tection of early urothelial mucosal changes but is
of findings, depending on the severity of infec- useful in determining the extent of renal and ex-
tion. Approximately 10%–15% of patients who trarenal spread of infection (3,16).
present with active renal tuberculosis will have Prior to the advent of the antituberculous drug
normal urographic findings (14). Parenchymal era, extirpative surgery was the only treatment
scars are common, being seen in over 50% of pa- available for patients with genitourinary tubercu-
tients (10). Irregularity of the papillary tips sec- losis (8). Without surgery, the 5-year survival rate
ondary to necrotizing papillitis (“moth-eaten” of patients with renal tuberculosis was 15%– 42%;
calices) is an early finding (10). Small cavities in surgical intervention increased the 10-year sur-
the papillae can progress to become medullary vival rate to approximately 50% (17). Early con-
cavities that communicate with the collecting sys- tinuous multidrug chemotherapeutic regimens
tem (4). Papillary cavitation results in the spread were successful in reducing mortality to a rate of
of infection to the urothelium and submucosa of 2.2% (18). The current standard of care for drug-
the draining calix. A fibrotic reaction develops, sensitive urinary tract tuberculosis in a compliant
which causes stenosis and strictures of the caliceal patient consists of a 6-month regimen of isoniazid
infundibula (4). Infundibular strictures can lead and rifampin, with pyrazinamide added for the
to localized caliectasis or incomplete opacification first 2 months (4). A fourth drug— ethambutol
of the calix (phantom calix) (11,15). Some pa- hydrochloride, streptomycin, or one of the fluoro-
tients may present with generalized hydronephro- quinolones—is typically included unless the pos-
sis (15). Scarring can cause sharp angulation of sibility of drug resistance is exceedingly small (4).
the renal pelvis (Kerr kink) (3). Ureteral involve- Despite treatment, strictures of the infundibula
ment occurs due to the passage of infected urine. and ureters can progress secondary to the body’s
Such involvement first manifests as dilatation and healing response. Surgical intervention is indi-
mucosal irregularity (sawtooth ureter), which may cated for management of complications, includ-
progress, with advanced disease, to the formation ing ureteral strictures (4). The issue of nephrec-
of strictures and ureteral shortening (pipe-stem tomy for management of a nonfunctioning end-
ureter) (11). Fusion of multiple strictures may stage tuberculous kidney is controversial. Several
create a long, irregular narrowing. Several non- authors maintain that a 2-year course of medical
confluent strictures can produce a “beaded” or treatment can sterilize the end-stage kidney (19),
“corkscrew” ureter (3). Reduced bladder capacity whereas others believe that the sequestered, case-
is the most common finding in tuberculous cysti- ous material should be removed to shorten the
tis. The bladder may be diminutive and irregular duration of medical therapy and to prevent late
with advanced disease (thimble bladder) (12). tuberculous reactivation (20).
CT is helpful in determining the extent of renal The differential diagnosis for the imaging ap-
and extrarenal spread of disease (6,16). CT is the pearance of renal tuberculosis includes chronic
most sensitive modality for identifying renal calci- pyelonephritis, papillary necrosis, medullary
fications, which occur in over 50% of cases of sponge kidney, caliceal diverticulum, renal cell
genitourinary tuberculosis (3). Coalesced cortical carcinoma, transitional cell carcinoma, and xan-
granulomas containing either caseous or calcified thogranulomatous pyelonephritis (7,12). The
material are readily identified at CT. Calices that most valuable radiologic feature of genitourinary
are dilated and filled with fluid have an attenua- tuberculosis is the multiplicity of abnormal find-
tion between 0 and 10 HU; debris and caseation, ings (3,4,6,16). Whenever a pattern of chronic
between 10 and 30 HU; putty-like calcification,
between 50 and 120 HU; and calculi, greater
than 120 HU (6). Cortical thinning is a common
256 January-February 2004 RG f Volume 24 ● Number 1

RadioGraphics renal inflammatory disease is recognized, particu- 10. Kollins SA, Hartman GW, Carr DT, Segura JW,
larly in the setting of periureteric or peripelvic Hattery RR. Roentgenographic findings in urinary
tract tuberculosis: a 10 year review. Am J Roent-
fibrosis, tuberculosis must be considered clini- genol Radium Ther Nucl Med 1974; 121:487–
cally (6). 499.
11. Engin G, Acunas B, Acunas G, Tunaci M. Imag-
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