Unexpected tuberculosis causing ureteral stricture

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A 72‐year‐old‐female was referred to our urology clinic with a 3‐month history of dysuria, intermittent right flank pain, measured fevers and the computerized tomography finding of a dilated right renal collecting system with abnormal wall thickening (Fig. 1). Prior to her referral, she had undergone an outpatient gastroscopy and colonoscopy to investigate these symptoms, which found no abnormality and she had completed a course of trimethoprim prescribed by a primary care physician. Her medical history included osteoarthritis and hypertension and her physical examination was unremarkable. She was prescribed an appropriate antibiotic for a resistant Enterococcus isolated from a recent urine culture and was booked for cystoscopy, retrograde pyelography and flexible pyeloscopy.
A cystoscopy was performed 3 weeks after clinic review and demonstrated several small erythematous patches on the bladder wall. Retrograde pyelography revealed multiple filling defects in the right renal collecting system from the mid‐ureter to the renal pelvis (Fig. 2) with no abnormalities on the left. Ureteroscopy of the right ureter was grossly abnormal, with cream‐colored pseudomembranous change from the mid‐ureter to the renal pelvis and areas of near total occlusion. Multiple biopsies of the abnormal ureteric material and erythematous bladder patches were collected, and a 4.8F multi‐length ureteric stent was placed.
A high fever (39.8°C) was recorded late on post‐operative day 1. Cultures were performed, a chest radiograph was unremarkable and a full blood count revealed neutropenia (0.8 × 109/L, reference range 2–7.5 × 109/L). Further history revealed that she had experienced drenching night sweats and fevers periodically for several months, and had a complicated recent travel history including Morocco, China, Cambodia, Thailand, Laos, Chile and Mexico. She had migrated to Australia 50 years previously from a rural area in Chile.
Microscopy of ureteric specimens revealed caseating and non‐caseating granulomas. She was placed in isolation and empiric anti‐tuberculosis therapy was commenced until she had resolution of her systemic symptoms. Urine specimens that had been sent for Mycobacterium tuberculosis polymerase chain reaction returned positive, confirming the diagnosis of genitourinary tuberculosis. She was discharged to the care of the tuberculosis physicians to complete treatment. Likely secondary to tubercular stricture, an attempt to remove her stent at 6 weeks resulted in pain, and a 6F ureteric stent was inserted, to be changed at 6 months. Genitourinary tuberculosis (TB) is the second most common extra pulmonary location of TB and is almost always fatal within 10 years of diagnosis if untreated.1 The kidneys are the most commonly affected genitourinary organ and become infected because of haematogenous spread. Tuberculosis may typically then involve any part of the urinary tract as a descending infection.
A long latent period, ranging from 1 to 10 years, is often seen after an episode of pulmonary TB.1 Ureteral TB presentations are diverse and commonly include drenching fevers and weight loss. Complications of ureteral TB include concomitant bacterial infection, ureteric stricture leading to hydronephrosis, renal failure and infertility.1
Surgical intervention is frequently required to ensure urine drainage in a scarred collecting system, to remove destructive lesions or entire organs if damage is severe, or if intractable hypertension or multi‐drug resistance is present.1
Recognition of genitourinary TB is difficult, primarily as clinical manifestations are diverse and the disease is exceedingly rare in Australia.4 Tuberculosis should be a consideration in patients who present with unusual histories, who fail to respond to standard treatment regimes, or have unexpected radiographic findings. A thick‐walled ureter in association with chronic fevers and pseudomembranous change on ureteroscopy should raise the clinical suspicion of genitourinary TB.

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