Diagnostic Ultrasound - Abdomen and Pelvis

Tuberculosis, Urinary Tract
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Diagnoses: Urinary Tract
Xanthogranulomatous Pyelonephritis (XGP)
• Enlarged kidney with highly reflective central echo complex
containing calculus
• Both XGP and renal TB show thickening of perirenal fasciae
and spread of inflammation into adjacent organs
Chronic Cystitis
• US: Irregularly thickened bladder wall and reduced bladder
volume
• Emphysematous cystitis: Highly reflective intramural gas in
bladder wall
PATHOLOGY
General Features
• Etiology
○ Infection by mycobacterium tuberculosis by
hematogenous spread from pulmonary TB
○ Occasionally, Mycobacterium bovis and Mycobacterium
avium-intracellulare (MAIC)
○ Reactivation of prior blood-borne dormant tubercle
bacilli
• Associated abnormalities
○ Males: Prostatitis, epididymitis, or orchitis
○ Females: Salpingitis, endometritis, or oophoritis (pelvic
inflammatory disease)
• Reactivation of dormant mycobacterium TB, which spread
into medulla causing papillitis
• Necrotizing papillae sloughed into calyces can both infect
and obstruct calyces, ureters, and bladder
• Ulceration of calyx gives typical ulcerocavernous lesion
• Fibrosis causes obstructive strictures leading to
hydronephrosis or pyonephrosis
• Infundibular stricture may result in chronic renal abscesses
• Healing results in fibrous tissue and calcium salts being
deposited, producing calcified masses
• Diffuse renal involvement with parenchymal destruction
and calcification
Gross Pathologic & Surgical Features
• Late stage: Small, irregular, fibrocalcific kidney
Microscopic Features
• Cortical granulomas consist of Langerhans giant cells
surrounded by lymphocytes and fibroblasts
• Papillary destruction extending into collecting system with
extensive fibrosis
• Multifocal infundibular, pelvic and ureteric fibrotic
strictures
• Diffuse parenchymal destruction and calcification
CLINICAL ISSUES
Presentation
• Most common signs/symptoms
○ Asymptomatic common
○ Earliest symptom: Frequency
○ Recurrent UTI: Flank pain, dysuria, fever
○ Sterile pyuria; gross painless hematuria
• Other signs/symptoms
○ Malaise, anorexia, weight loss, night sweats,
hypertension
○ Prostatic enlargement ± tenderness (male)
○ Infertility, pelvic pain, or abnormal menstrual bleeding
(female)
Demographics
• Age
○ Usually 2nd-4th decades, due to longer latency between
pulmonary disease and renal manifestation
• Epidemiology
○ < 2% in developed countries
○ > 20% in developing countries
○ M:F = 2:1
Natural History & Prognosis
• Renal infection → obstructive uropathy → renal failure
• Complications: Hydronephrosis, abscess formation,
hypertension, extrarenal spread
• Low mortality but high morbidity
• High relapse rate in patients with poor nutritional status
and social condition
• Extrarenal manifestation like pelvic inflammatory diseases
in women
Treatment
• Antituberculosis chemotherapy usually followed by surgical
intervention
• Surgical intervention
○ Percutaneous balloon stenting for strictures
○ Partial or total nephrectomy to remove large foci of
infection in renal calcifications or for extensive renal
damage
○ Cystectomy and substitution cystoplasty for extensive
bladder damage
DIAGNOSTIC CHECKLIST
Consider
• TB if concurrent multiple abnormalities exist in urinary tract
or in patient with known tubercular disease
• Chest radiography to look for primary TB focus
• Biopsy of lesions, urinalysis, and culture
Image Interpretation Pearls
• Abnormalities in multiple sites: Renal parenchymal
mass/cavitation ± hydrocalyces/hydronephrosis ± UT
calcifications ± small and thick-walled bladder
SELECTED REFERENCES
1. Merchant S et al: Tuberculosis of the genitourinary system-Urinary tract
tuberculosis: Renal tuberculosis-Part I. Indian J Radiol Imaging. 23(1):46-63,
2013
2. Merchant S et al: Tuberculosis of the genitourinary system-Urinary tract
tuberculosis: Renal tuberculosis-Part II. Indian J Radiol Imaging. 23(1):64-77,
2013
3. Vijayaraghavan SB et al: Spectrum of high-resolution sonographic features
of urinary tuberculosis. J Ultrasound Med. 23(5):585-94, 2004
4. Wang LJ et al: Imaging findings of urinary tuberculosis on excretory
urography and computerized tomography. J Urol. 169(2):524-8, 2003
5. Wise GJ et al: Genitourinary manifestations of tuberculosis. Urol Clin North
Am. 30(1):111-21, 2003
6. Goel A et al: Autocystectomy following extensive genitourinary tuberculosis:
presentation and management. Int Urol Nephrol. 34(3):325-7, 2002
7. Izbudak-Oznur I et al: Renal tuberculosis mimicking xanthogranulomatous
pyelonephritis: ultrasonography, computed tomography and magnetic
resonance imaging findings. Turk J Pediatr. 44(2):168-71, 2002
8. Premkumar A et al: CT and sonography of advanced urinary tract
tuberculosis. AJR Am J Roentgenol. 148(1):65-9, 1987