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An Unusual Presentation of Renal Tuberculosis During Pregnancy

ABSTRACT

Reports from the World Health Organization estimate that nearly one third of the world's population is infected with Mycobacterium tuberculosis. The present case is a 33-year-old woman who was pregnant in the first trimester. She presented with mild fever and left flank pain and was treated for renal abscess. Postpartum investigations revealed renal tuberculosis (TB), necessitating medical treatment and open surgery drainage. The diagnosis of genitourinary TB is difficult because its symptoms are nonspecific, but early diagnosis is essential for successful management. Screening of TB should be considered for the following groups of pregnant women: (1) patients with symptoms suggestive of TB; (2) patients with HIV infection; (3) patients who were in close contact with infectious TB; and (4) patients who recently visited countries with high TB-prevalence. The authors report the case with a review of the literature.

KEYWORDS: Genitourinary tuberculosis; Pregnancy; Abscess.

CORRESPONDENCE: Dr. Sataa Sallami, Department of Urology, La Rabta Hospital-University, Tunis 1007, Tunisia ().

CITATION: UroToday Int J. 2010 Jun;3(3). doi:10.3834/uij.1944-5784.2010.06.05

ABBREVIATIONS AND ACRONYMS: ESR, erythrocyte sedimentation rate; GUTB, genitourinary tuberculosis; M. tuberculosis, Mycobacterium tuberculosis; TB, tuberculosis; WHO, World Health Organization.

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INTRODUCTION

Tuberculosis (TB) is a systemic infection caused by Mycobacterium tuberculosis (M. tuberculosis). Extrapulmonary TB accounts for 10% to 27% of all cases [1]. Because information on the outcome of pregnancy among women with extrapulmonary TB is limited, the authors report an unusual case of renal TB in a pregnant woman.

CASE REPORT

A 33-year-old pregnant woman presented to the authors' department in January, 2005. She was gravida 1 and at 12 weeks gestation. She complained of fever and left flank pain. She had a history of intermittent fever, night sweats, and weight loss. She had no family history of TB or respiratory symptoms. The right kidney was absent because of a congenital malformation.

Evaluation

On admission, the patient had mild pyrexia of 38.2oC, a pulse rate of 100 beats per minute, and blood pressure of 130/85 mm Hg. Abdominal examination revealed left flank tenderness without any palpable lumbar mass or palpable lymph node.

Laboratory examination showed the following: (1) hemoglobin, 12 g/dL, (2) white cell count, 13.3x106, (3) serum creatinine, 160 μmol/L, (4) erythrocyte sedimentation rate (ESR), 57 mm/h, and (5) C-reactive protein, 200 mg/L. Liver function test, glucose, and electrolytes were within normal range. Urine culture was normal. Tests for human immunodeficiency virus (HIV) and hepatitis B were negative.

Ultrasonography revealed a monofetal evolutive pregnancy. The patient had a solitary left kidney with a cystic lesion in the upper pole. The cyst had a thick wall Figure 1 and measured 3 cm. The renal cavities were not dilated.

Although the patient had no history of TB or recent exposure, all patients with renal abscess in the authors' department are routinely tested for TB because of its high prevalence in Algeria. Therefore, 4 separate early-morning urine specimens were tested for TB; the results were negative.

Initial Management

With the diagnosis of a small (< 4 cm) renal abscess, the patient was treated with ampicillin (2g per day) for 21 days with good evolution. She had a successful vaginal delivery at normal gestation time. The infant had a normal birth weight (3200 g) and an Apgar score of 8.

Follow-up Evaluation and Management of TB

A second ultrasonography was performed for routine monitoring. It showed multiple cystic lesions in the left renal parenchyma (Figure 2). A chest X-ray was normal. A computed tomography (CT) scan revealed multiple renal abscesses in a unique left kidney (Figure 3).

Percutaneous drainage was performed, but it was insufficient because of the large number of abcesses. Bacterial analysis revealed Escherichia coli (E. coli). Surgical drainage of the abscess cavities was performed and a biopsy was taken from the wall. Postoperatively, the patient had an uneventful early recovery.

The pathological examination showed chronic caseating granulomatous inflammation. Fully sensitive M. tuberculosis was subsequently grown from the biopsy material. The patient was diagnosed with TB.

The patient began quadruple antituberculosis therapy for 2 months (pyrazinamide 1500 mg per day, ethambutol 900 mg per day, isoniazid 900 mg per day, and rifampicin 600 mg per day). This course was followed by double therapy (isoniazid and rifampicin) for another 6 months.

The infant was in very good health with normal ESR. He did not require any treatment.

Ten months later, the patient was well with no evidence of ongoing TB. She had stable, normal renal function (plasma creatinine 120 μmol/L). ESR fell to 5 mm/h and CRP to 9 mg/L. A chest X-ray and renal ultrasonography were normal.

DISCUSSION

TB has been observed for 7000 years [2]. It is a major public health concern worldwide [3]. Reports from the World Health Organization (WHO) estimate that nearly one third of the world's population is infected with M. tuberculosis [4].

Although the lung remains the most common site of infection, extrapulmonary disease is becoming more prevalent [3,5] and the increase is more pronounced among young women [5]. Genitourinary tuberculosis (GUTB) remains one of the most common forms of secondary or extrapulmonary disease, accounting for 20% to 73% of all cases in the general population [2].

The reported sites of extrapulmonary TB in pregnancy include the lymph nodes, intestines, skeleton, kidney, meninges, endometrium, mediastinum, and pleura [1,6,7]. The psoas and lumber spine have also been reported [8,9]. Information about pregnant women with extrapulmonary TB is scanty and usually in the form of case reports or case series [10]. TB during pregnancy is extremely rare and considered a severe form of extrapulmonary TB [4].

In a report from New York City covering the period of 1991-1992, TB was diagnosed in 16 mothers among 51 983 births. Six of the 16 women had extrapulmonary TB [6]. Unlike the present patient, GUTB is rare among people under the age of 25 years. These patients are more likely to have a family history that is positive for TB [11].

High rates of TB are associated with socioeconomic crisis, weaknesses in health systems, epidemics of HIV and multidrug-resistant TB, and poor interventions to control TB among vulnerable populations [2]. Although renal TB is uncommon in developed countries, as many as 15% to 20% of patients with TB in developing countries have M. tuberculosis in the urine [12].

TB may involve the kidney as part of generalized disseminated infection or as localized genitourinary disease. The kidney is usually infected by hematogenous spread of bacilli from a focus of infection in the lungs and/or bowel. Typically, GUTB is a reactivation of the TB from a period of dormancy [12]. Clinically, renal TB is usually unilateral, but postmortem studies have shown that the disease frequently was bilateral [2]. The originality of the present case is that this patient had a unique congenital kidney affected by the disease.

Diagnosis of GUTB

The diagnosis of GUTB is difficult because its symptoms are nonspecific. The most important step in diagnosing GUTB is patient history. TB infection early in life, either as a primary pulmonary or extrapulmonary manifestation, gives an important clue in a large number of cases. The physician has to be aware that the latency between pulmonary manifestation and GUTB is potentially enormous. In some cases, it could take more than 30 years before GUTB becomes evident [8].

Symptoms of GUTB that sometimes occur include back, flank, and suprapubic pain, hematuria, frequency, and nocturia. Renal colic is uncommon (occurring in fewer than 10% of patients) and constitutional symptoms such as fever, weight loss, and night sweats are unusual [2]. Commonly, the symptoms are intermittent, fairly nonspecific, and present for some time before the patient seeks medical advice [13,14].

The urine is normally sterile and it contains leukocytes in a high proportion of patients. However, up to 20% of patients may not have any leukocytes in the urine [12]. Therefore, urologists should always consider the diagnosis of GUTB in a patient presenting with vague, long-standing urinary symptoms for which there is no obvious cause.

The most common laboratory abnormalities are pyuria, albuminuria, and hematuria. It has been reported that 75% of patients have an abnormal chest roentgenogram on admission, 88% have positive skin tests, 63% have abnormal excretory urography, and 16% show renal calcification [15]. A microbiologic diagnosis of TB is usually made by isolation of the causative organism from urine or biopsy material [2]. Renal TB is accompanied by manifestations of the urinary syndrome in 70.4% of cases and by the presence of M. tuberculosis in 100% [16].

TB and Pregnancy

Pregnancy has no adverse effect on TB if the diagnosis is not delayed [17]. Unfortunately, the diagnosis of TB during pregnancy is usually delayed for 2 weeks to 30 weeks because of its nonspecific symptoms and protean manifestation. Up to 20% of pregnant women with TB are asymptomatic or have atypical symptoms [18]. In addition, lack of biopsies and appropriate imaging during pregnancy makes the diagnosis more difficult [14].

TB is associated with increased rates of maternal disability, hospitalization during pregnancy, fetal-growth retardation, and low Apgar scores soon after birth [6]. Because TB is more dangerous than drug toxicity for pregnant women, medication is advised to treat the disease. Termination of pregnancy is not recommended unless the patient is unresponsive to medication. In addition, pregnancy does not increase the risk of relapse or deterioration of TB in the patients who are adequately treated [14].

Treatment with antituberculosis drugs poses special problems during pregnancy because of concern about potential teratogenic effects. The present patient received 4 drugs, all of which are relatively safe to use during and after pregnancy [1]. Although the drugs can get into breast milk, most of the drugs used to treat TB have no reported toxic or teratogenic effects [17], except for pyrazinamide and streptomycin.

Modern short-course antituberculous drug regimens are effective for all forms of TB. According to the WHO, the antituberculous drug treatment is based on an initial 2-month intensive phase of treatment with 3 or 4 drugs daily. These drugs include rifampicin, isoniazid, pyrazinamide, and ethambutol (or streptomycin). They are administered to destroy almost all tubercle bacilli. This treatment is followed by a 4-month continuation phase with only 2 drugs, most commonly rifampicin and isoniazid. In the continuation phase, the drug may be given 2 or 3 times weekly. The present patient had a complicated GUTB, so the authors used an 8-month short course of the antituberculous drug regimen [2].

Although chemotherapy is the mainstay of treatment, ablative surgery as a first-line management may be unavoidable for sepsis or abscesses [19]. The contents of an abscess should be aspirated in a minimally invasive manner [12]. Open surgical drainage of the abscess is indicated as a second attempt when there is insufficient percutaneous drainage, as in the present case.

The obstetric outcomes of the patients depend on the severity and duration of the disease and the occurrence of pregnancy-associated complications [14]. The present authors concur with a previous report stating that the most crucial step in managing TB in pregnancy is early diagnosis [20]. Delay in diagnosis could be very serious. Obstetricians and urologists should be alert to this “old disease” in their daily practice. Screening of TB should be considered for the following groups of pregnant women: (1) patients with symptoms suggestive of TB; (2) patients with HIV infection; (3) patients who were in close contact with infectious TB; and (4) patients who recently visited countries with high TB-prevalence [14]. The most appropriate method for screening TB infection is the tuberculin skin test. However, the test may be false-negative because of age, poor nutrition, immunosuppression due to disease or drugs, viral infections, and overwhelming TB [14].

CONCLUSION

TB remains a major global public health problem in developing countries. The prognosis depends on early diagnosis (which may be difficult because of nonspecific symptoms) and timely commencement of the appropriate treatment. Practitioners should be alert to the possibility of extrapulmonary TB, especially in high risk populations.

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