Other Infections

Diagnosis

  • Clinical Features and Diagnosis
    • Renal involvement is largely silent, often presenting vague urinary symptoms
    • History taking and high index of suspicion as well as a history of recurrent urinary tract infections that are nonresponsive to common antibiotics
    • Male: the earliest indication may be tuberculous epididymitis or cystitis
    • Female: may present with bladder pain and dysuria
    • Back pain and hematuria are not uncommon
    • A recurrent Escherichia coli infection should serve as a warning sign
  • Clinical Findings in Genitourinary Tuberculosis
    • Sterile pyuria
    • Nocturnal painless frequency of micturition
    • History of present or past TB elsewhere in the body
    • Unexplained hematuria
    • Chronic cystitis unresponsive to antibiotics
    • Chronic epididymitis with epididymal nodularity and/or thickened or beaded vas deferens
    • Nodularity of prostate, shrunken "bean bag" prostate
    • Induration of seminal vesicles
    • Dull flank pain and renal colic
    • Chronic draining scrotal sinus
    • Hemospermia (rare)
  • Severity of symptoms do not correlate with the degree of urinary tract involvement
  • Diagnosis is made by finding M. tuberculosis in the urine or semen
    • Three to five consecutive early morning urines are cultured: repeat if results are negative
    • Acid-fast stains on concentrated urinary sediment from 24-hour specimen may be positive in 50 to 60 percent of cases, but culture corroboration is essential. Once the cultures are positive, the antibiotic sensitivities are performed.
      • Fluorescence microsopy and other modern diagnostic techniques have enhanced the yields
      • DNA probes have allowed clinicians to differentiate between various mycobacterial species and strains
    • A negative tuberculin skin test makes the diagnosis unlikely, but a conversion of previously negative test to positive should raise the index of suspicion
    • Radiographs alone are not sufficient for diagnosis. However, an intravenous urogram may reveal various features of TB and helps rule out obstruction and non functioning unit.
    • Drug-sensitivity testing is essential. Differential diagnosis
    • Chronic nonspecific cystitis or pyelonephritis
    • Acute or chronic nonspecific epididymitis
    • "Urethral syndrome," interstitial cystitis
    • Necrotizing papillitis of one or both kidneys
    • Schistosomiasis

Medical Management

  • General considerations:
    • The aim of antituberculous therapy is to treat the active disease promptly and render the patient noninfective in the shortest period of time
    • The size of the bacillary population is related to the extent of the disease
    • Multiple drugs work synergistically against resistant organisms in early treatment
    • Close follow-up of upper tracts is essential during therapy, as asymptomatic uretetal strictures (especially in the lower third) may occur during the healing phase
    • Tuberculous strictures lend themselves to percutaneous or transurethral dilatation techniques
    • Steroids may be beneficial

Surgical Management

  • Surgical intervention may play an increasing role with trends toward shorter duration of chemotherapy

Medical Management Subject to Sensitivity Results

  • Primary agents: rifampicin, isoniazid, pyrazinamide, and streptomicin
    • Currently, a combination therapy is employed, usually for 4 to 6 months
    • Combination therapy popularized by Gow includes: pyrazinamide, 25 mg/kg daily plus INH, 300 mg daily and rifampin, 450 mg daily for 2 months followed by isoniazid 600 mg and rifampin 900 mg three times weekly for a further 2 months
  • Secondary agents: ethambutol, ethionamide, cycloserine, para aminosalycic acid, and capreomicin

Common Antituberculous Chemotherapeutic Agents
DRUG DOSES SIDE EFFECTS NOTES
Capreomycin 500-1000mg/dayonce per day for 3 monthsthen twice per week Nephrotoxicity ototuxicity Use with caution in elderly
Cycloserine 10-20 mg/kg per day to maximum 500 mg/day Psychosis Contraindicated in epileptics
Ethambutol 15 mg/kg per day Retrobulbar neuritis, color vision changes Tuberculostatic baseline visual acuity tests
Isoniazid (INH) 5-10 mg/kg per day max 300 mg/day Peripheral neuritis, hepatitis Bactericidal, pyridoxin for neuritis
Pyrazinamide 15-30 mg/kg to max 2000 mg/day Hepatotoxicity, elevates serum uric acid Monitor Liver function and serum uric acid
Para-aminosalicylic acid 150 mg/kg to max 12 g/day Hypersensitivity, GI irritation, hepatotoxicity Tuberculostatic
Rifampicin 10-20 mg/kg per day to maximum 600 mg/day Hepatotoxicity, hypersensitivity, transient leukopenia, thrombocytopenia Bactricidal, orange discoloration of urine
Streptomycin 750-1000 mg/day IM for 1 month, then 95 mg/kg twice per week Nephrotoxicity, ototoxicity  

Surgical Therapy Subject to Sensitivity Results

  • Surgery, when indicated, is performed 4 to 6 weeks after chemotherapy has begun
  • Surgical procedures are undertaken to drain perinephric abscess, remove nonfunctioning renal tissue, bypass ureteral strictures, and to augment severely contracted bladders
  • Nephrectomy is done for grossly diseased nonfunctioning kidney or diseased kidney with severe secondary hypertension
  • Partial nephrectomy is some times undertaken for calcified polar lesion increasing in size
  • Reconstructive surgery is performed as necessary

Follow-up

  • Patients should be seen at 3, 6, and 12 months after completion of therapy and their urines cultured for acid-fast bacillus (AFB)
  • Patients can discharged following a year of disease-free follow up
  • Kidney, ureter, and bladder (KUB) x-rays and intravenous urography (IVU) are required to follow the status of calyceal deformities and renal calcifications

References


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