seminar renaltb 110713085451 phpapp02

8/2/2019 Seminar Renaltb 110713085451 Phpapp02

1/57

Click to edit Master subtitle style

.

GenitourinaryTuberculosis


2/57

Etiology

Genus Mycobacterium

Weakly gram+ive,Acid fast

- i i i i i i


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


4/57

Hematogenous spread

Rarely primary one

Transplant recipient


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.


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


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.


8/57

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


9/57

Fibrosis accompanies the granulomatous process

infundibular stricturesand renal pelvic kinking

obstructive uropathy

The end-stage kidney is nonfunctional


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


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


12/57

Pathology: Gross

Renal tuberculosis. Photograph of a cut gross specimen shows

multiple, predominantly peripheral, white tuberculous

granulomas throughout the kidney.


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)


14/57

Calcification in advanced lesions is common and may be focalor generalized, which produces a putty or cement kidney.


15/57

Caseating granuloma

Bilateral microscopic renalinvolvement is the rule.

Pathology: Microscopic


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


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


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)

-


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


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


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


22/57

Three other major complications of renal tuberculosis:

hypertension (RAS axis mediated)

super-infection (12 to 50%)

nephrolithiasis (7 to 18%).


23/57

Female--Infertility,menstrualdisturbances,vaginal discharge,pelvic pain

Male--Scrotal pain orswelling,haemospermia,superficial penileulceration

Diagnosis


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


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.


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


27/57

Gold standard

positive in 80% to 90% of cases

Decontamination of sediment.

main problems:

-COST

-AVAILABILITY

-DELAYS

Culture


28/57


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


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


31/57

Plain radiograph of the abdomen demonstrates extensivecalcification in the left kidney, which was nonfunctional (the puttykidney), consistent with autonephrectomy from tuberculosis.


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


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


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


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


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.


37/57

Genitourinary tract tuberculosis. Lobar calcification in alarge destroyed right kidney in a patient with renaltuberculosis. Note the involvement of the right ureter.


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.


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


40/57


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


42/57

Click icon to add picture

PUTTYKIDNE

Y.


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).


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-


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.


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


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


48/57

Two goals

Clinical Management

conservation of tissue

and functionantimycobacterial cure.


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


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.


51/57

INHRifampicin no adjustment

Pyrazinamide

Drug Cr. Clearance Dose interval

Ethambutol 10-50 ml/min 24-36 hrs


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


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


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?


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


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.


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

seminar renaltb 110713085451 phpapp02

Documents