Renal Tuberculosis: An Uncommon Presentation of a Common Disease: Case Report

Introduction: Guatemala is an endemic country for tuberculosis (TB) with 3 500 cases per year, 85% correspond to pulmonary presentation. Genitourinary tuberculosis is uncommon, it is considered a severe form of extrapulmonary TB;it is secondary to infection with Mycobacterium tuberculosis complex with a long-standing dysuria, sterile pyuria, fever and consumptive symptoms. We present the case of an atypical renal TB having hematuria and fever as the only clinical features. Case Description: A 54-year-old Guatemalan male came to the emergency room with a history of intermittent fever during the last year that worsens in the last 2-weeks. He lived in a rural area at the southern-coast of Guatemala. No previous medical history, no pets at home. The fever was between 38.3-40o (100-104oF) with no predominant pattern during the day. On admission, normal vital signs, dehydrated with no other sign or symptom at physical examination. Initial laboratories with WBC 6 500, Hb 13gr/dl, SCr 0.86mg/dl, BUN 15mg/dl, normal LFTs and electrolytes. Chest X-ray with no evidence of pneumonia or other pulmonary disease. Urinalysis with microscopic hematuria with >30 RBCs per hpf, 40% of dysmorphism;no WBC in three consecutive urinary test. Urinary protein-creatine ratio15mg/g. Negative urine culture. ANA, ANCAs, C3, C4 were negative. Infectious disease tests were negative (FilmArrayâ, TORCH, blood culture, SARS-Cov2, HIV, HBV, HCV, lumbar puncture). Considering hematuria from urological origin we perform a uro-CT which was negative for kidney stones, masses or other anatomical abnormalities. Urine Ziehl-Nielsen stain was negative but with a positive result for acid fast bacilli in urine Kinyoun stain (figure 1). A multidrug therapy was started with isoniazid, pyrazinamide, ethambutol, rifampicin. Forty-eight hours later the fever disappeared until discharged. Discussion: Renal TB has a prevalence of 10% worldwide and 20% in Latin-America mainly from pulmonary origin. The reported cases have higher prevalence in developing countries, male gender, immunosuppressed state as in HIV infection and post transplanted. It is an under diagnosed disease that can lead to CKD. The diagnosis of renal TB must be considered in patients with dysuria, hematuria, pyuria with negative urinary cultures.