Imaging spectrum of genitourinary tuberculosis: Our experience at a tertiary care centre of a third world country

Transcription

1 Imaging spectrum of genitourinary tuberculosis: Our experience at a tertiary care centre of a third world country Poster No.: C-361 Congress: ECR 2009 Type: Educational Exhibit Topic: Genitourinary Authors: Z. A. Khan, S. Ahmad; Al-Ahsa/SA Keywords: extrapulmonary tuberculosis, Genitourinary tuberculosis, Urinary tract infections DOI: /ecr2009/C-361 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 45

2 Learning objectives 1) To illustrate the spectrum of genitourinary tuberculosis in a tertiary care centre of a third world country where the disease is endemic. 2) To outline its salient differentiating features. Background The Tuberculosis (TB) is a global emergency particularly with the growing infection rate of AIDS worldwide. Genitourinary tuberculosis (GUTB) is an example of secondary tuberculosis and is the 3rd commonest extra pulmonary lesion. The incidence of GUTB is also increasing especially in the developing countries where the incidence can be five times higher than in the western countries (1). This could be a reflection of the social deprivation, poor diet and over crowded living conditions that have a direct effect on the disease by increasing the susceptibility. GUTB is an example of secondary TB caused by metastatic spread of organisms through hematogenous route. The other routes are descent via the urinary tract, lymphatic spread and by direct extension. All structures of the urinary system and genital tract may become involved later on. The clinical symptoms usually develop years after the primary infection (2). Pathophysiology The initial lesion involves the renal cortex with several small granulomas, they are typically bilateral, and adjacent to the glomeruli and may remain inactive for decades. Clinical symptoms do not develop until the calyces or pelvis is involved. Depending on the status of the patient's defense mechanisms, fibrosis and strictures may develop. In advanced cases parenchymal destruction occurs, with areas of caseation and abscess formation. Extensive lesions can result in nonfunctioning kidneys. Ureterl TB is an extension of the disease from the kidneys, generally to uretrovesical junction. It only rarely affects the middle third of the ureter. Extensive fibrosis shortens the length of ureter pulling up the orifice as a gaping hole, the so called "golf-hole" appearance of the ureteric orifice. Bladder TB usually starts at the ureteral orifice. Fibrosis of the ureteral orifice can lead to stricture formation with hydronephrosis or scarification (i-e, golf-hole appearance) with vesicoureteral reflux (2). Severe cases involve the entire bladder wall resulting in thick fibrous reduced capacity bladder. The high frequency of isolated epididymal TB lesions in children favors the possibility of hematological spread of infection, while adults seem to develop by direct spread from the urinary tract. Page 2 of 45

3 Involvement of testis and urethra are usually due to direct extension while the prostatic TB results from hematogenous route, but involvement is rare. Imaging findings OR Procedure details In this exhibit, we present imaging features in 122 patients who had tuberculous involvement of various parts of genitourinary tract including kidney, ureter, urinary bladder, prostate, testis and urethra (Table-1). The female genital tract cases are usually referred to gynecology unit, therefore, these cases are not included in our exhibit. These patients were diagnosed and treated at Sindh Institute of Urology and Transplantation, Karachi over a period of 10 years. The diagnosis was based on microbiological and histopathological grounds. In a few cases the diagnosis was presumptive where clinical and radiological features were suggestive and anti tuberculous treatment resulted in improvement (Chart-1). The patient's demographics and clinical presentations are shown in Chart-2 and Chart-3. Imaging Features Radiological diagnosis of GUTB begins with careful examination of the plain films. In the presence of urinary symptoms, a CXR showing evidence of TB should make the physician aware of the possibility of co-existent GUTB. Out of 122 patients, 18 patients had associated active or inactive pulmonary tuberculosis. Deposition of calcium in an attempt to heal tuberculous lesions often provides a major diagnostic clue. Renal Tuberculosis Although both the kidneys may be seeded, the clinically apparent disease is usually unilateral. Bilateral involvement was noted in our 19 cases. Fifty patients had non functioning diseased kidney and 20 patients had associated urinary calculi. - Calcifications with in the renal parenchyma (Fig-1) which may be amorphous, granular, curvilinear, or lobar (3). - Moth eaten calyx due to erosion (Fig-2) is the earliest urographic finding (4). - Irregular pools of contrast material outside the calyx (Fig-3). - Various patterns of hydronephrosis (focal caliectasis, caliectasis without pelvic dilatation, and generalized hydronephrosis) Fig-4. Page 3 of 45

4 - Infundibular stenosis with pinched-off cyst like structure (Phantom calyx) (5) or calyceal distortion (Fig-5). - Focal or global poor renal function (Fig-6). - Cortical scarring and hypoechoic/hypodense parenchymal lesions. The radiological differential diagnosis of renal TB includes other causes of papillary necrosis, transitional cell carcinoma, and other infections. Ureteral TB Ureteral involvement is seen in 50% of patients with GUTB (6). - Early signs at urography are ureteral dilatation and a ragged appearance of the ureter (Fig-5). - Occasionally filling defects due to mucosal granulomas may be seen (Fig-7). - Short or long segment ulceration of the ureter. - Strictures of variable length which may be single or multiple resulting in beaded, corckscrew or pipe stem appearance (4, 7) Fig6 and 8. - Ureteric calcifications are an infrequent finding. Calcifications are intraluminal (Fig-9), as opposed to schistosomiasis which produces intramural calcifications. The differential diagnosis of ureteral TB includes ureteral stones and calcifications caused by schistosomiasis. Bladder TB -The classical finding in tuberculous cystitis is contracted and spastic bladder of reduced capacity (6) which was seen in 32 of our cases.(fig-10). - Occasionally filling defects due to multiple granulomas (Fig-11). - Diverticulum caused by marked scarring with deformity of one portion of the bladder - In advanced disease bladder may be diminutive and irregular (thimble bladder) Fig-12. Page 4 of 45

5 - Vesicoureteral reflux due to fibrosis involving ureteral orifice (Fig-13). - Calcification of the bladder wall is rarely seen. The radiological differential diagnosis for tuberculous bladder calcification includes schistosomiasis, cytoxan cystitis, radiation induced bladder calcification, calcified bladder carcinoma, and encrusted foreign materials. Bladder tuberculomas must be differentiated from transitional cell carcinoma. Genital tract TB Genital TB affects both males and females. Female genital tract TB is not being discussed here as mentioned before. In males, tuberculous involvement of the prostate gland or seminal vesicles may lead to necrosis, calcification, caseation, and cavitation (3, 8) Fig-14. Tuberculous epididymo-orchitis usually manifest at ultrasonography as focal or diffuse areas of decreased echogenecity with epididymal involvement. Calcifications can be seen. (Fig-15). Urethral TB is secondary to genital TB. Acute urethritis manifests as mycobacterial discharge and often results in chronic stricture formation (Fig-11 & 16). Tuberculous involvement of penis was noted in one patient who presented with penile ulcer. Images for this section: Page 5 of 45

6 Fig. 1: Genito urinary organs involved by Tuberculosis Page 6 of 45

7 Fig. 2: Basis of diagnosis Page 7 of 45

8 Fig. 3: Demographics Page 8 of 45

9 Fig. 4: Clinical presentations Page 9 of 45

10 Fig. 5: Various patterns of renal parenchymal calcifications in cases of Renal TB. (a) Amorphous, (b) Granular, (c) Curvilinear and (d) Lobar (autonephrectomy). Page 10 of 45

11 Fig. 6: Various patterns of renal parenchymal calcifications in cases of Renal TB. (a) Amorphous, (b) Granular, (c) Curvilinear and (d) Lobar (autonephrectomy). Page 11 of 45

12 Fig. 7: Various patterns of renal parenchymal calcifications in cases of Renal TB. (a) Amorphous, (b) Granular, (c) Curvilinear and (d) Lobar (autonephrectomy). Page 12 of 45

13 Page 13 of 45

14 Fig. 8: Various patterns of renal parenchymal calcifications in cases of Renal TB. (a) Amorphous, (b) Granular, (c) Curvilinear and (d) Lobar (autonephrectomy). Page 14 of 45

15 Page 15 of 45

16 Fig. 9: Spot film from retrograde pyelography shows moth-eaten pelvicalyceal system communicating with parenchymal abscess cavity. Fig. 10: Renal Tuberculosis (a) spot film from IVU study shows distorted upper pole calyces with moth eaten erosions and irregular pooling of contrast.(b) dilated and distorted left pelvicalyceal system communicating with irregular pools of contrast medium represents abscess cavities in early TB. Page 16 of 45

17 Fig. 11: Renal Tuberculosis (a) spot film from IVU study shows distorted upper pole calyces with moth eaten erosions and irregular pooling of contrast. (b) dilated and distorted left pelvicalyceal system communicating with irregular pools of contrast medium represents abscess cavities in early TB. Page 17 of 45

18 Fig. 12: Axial CT scans in 2 different patients showing (a) Scarred hydronephrotic right kidney with perinephric fat stranding and nephrostomy tube. Left kidney is calcified representing autonephrectomy. (b) Hydronephrotic right kidney due to renal pelvic scarring. Page 18 of 45

19 Fig. 13: Axial CT scans in 2 different patients showing (a) Scarred hydronephrotic right kidney with perinephric fat stranding and nephrostomy tube. Left kidney is calcified representing autonephrectomy. (b) Hydronephrotic right kidney due to renal pelvic scarring. Page 19 of 45

20 Page 20 of 45

21 Fig. 14: Spot film from IVU shows calyceal distortion and dilated ureter with ragged appearance. Page 21 of 45

22 Fig. 15: Non functioning calcified left kidney. Right pelvicalyceal system and ureter are dilated due to distal ureteric stricture. Page 22 of 45

23 Page 23 of 45

24 Fig. 16: (a) Left ante grade pyelography and (b) IVU spot film in two different patients showing dilated and distorted pelvicalyceal systems with nodular filling defects involving both pelvicalyceal systems and proximal ureters. Page 24 of 45

25 Page 25 of 45

26 Fig. 17: (a) Left ante grade pyelography and (b) IVU spot film in two different patients showing dilated and distorted pelvicalyceal systems with nodular filling defects involving both pelvicalyceal systems and proximal ureters. Page 26 of 45

27 Page 27 of 45

28 Fig. 18: Beaded appearance of left ureter and faint opacification of pyonephrotic left pelvicalyceal system. Page 28 of 45

29 Page 29 of 45

30 Fig. 19: (a & b) Plain X-rays of two different patients show calcified kidneys and ureteric calcifications. Page 30 of 45

31 Page 31 of 45

32 Fig. 20: (a & b) Plain X-rays of two different patients show calcified kidneys and ureteric calcifications. Page 32 of 45

33 Page 33 of 45

34 Fig. 21: Right ante grade pyelogram showing dilated pelvicalyceal system and ureter with contracted and small capacity bladder. Page 34 of 45

35 Page 35 of 45

36 Fig. 22: Beaded appearance of urethra and small capacity U.B. with a filling defect along its superior wall due to granuloma. Page 36 of 45

37 Page 37 of 45

38 Fig. 23: IVU: Small capacity irregular urinary bladder with right distal ureteric stricture and hydroureter.left kidney is non functioning with fine granular parenchyml calcifications. Page 38 of 45

39 Page 39 of 45

40 Fig. 24: Urethrogram: Small capacity urinary bladder with left vesicoureteric reflux due to golf-hole deformity of uretero vesical junction Fig. 25: Plain X-ray film showing diffuse prostatic calcifications. Page 40 of 45

41 Fig. 26: U/S left testis showing hypoechoic lesions along with linear calcification. Page 41 of 45

42 Page 42 of 45

43 Fig. 27: Urethrogram study delineates urethral strictures and right vesico ureteric reflux. Page 43 of 45

44 Conclusion Tuberculosis remains a significant health problem throughout the world especially in developing countries. Our experience suggest that a CXR showing evidence of active or healed tuberculosis should make the physician aware of co-existing urogenital involvement in the presence of urinary symptoms. Imaging studies are only suggestive or compatible for the disease and these studies should not be used for confirmation or exclusion of urinary tract tuberculosis. Personal Information References 1. SA Naqvi and SAH Rizvi. Genitourinary tuberculosis. European Urology Update Series 1996; 5: MS Soliman, KD Lessnau, and A Hashmat. Tuberculosis of the genitourinary system. emedicine.medscape.com/article/450651; updated Dec 27, Wang LJ, Wong YC, Chen CJ, et al. CT features of genitourinary tuberculosis. J Comput Assist Tomogr 1997; 21: MG Harisinghani, TC Mc Loud, JD Shepard, et al. Tuberculosis from Head to Toe. Radiographics 2000; 20: Brennan RE, Pollack HM. Non visualized ("phantom") renal calyx: causes and radiological approach to diagnosis. Urol Radiol 1979; 1: Leder RA, Low VH. Tuberculosis of the abdomen. Radiol Clin North Am 1995; 33: Birnbaun BA, Friedman JP, Lubat E, et al. Extra renal genitourinary tuberculosis: CT appearance of calcified pipe-stem ureter and seminal vesicle abscess. J Comput Assist Tomogr 1990; 14: Wang JH, Chang T. Tuberculosis of the prostate: CT appearance. J Comput Assist Tomogr 1991; 15: Page 44 of 45

45 Page 45 of 45