Case report1-1-1

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Case 1-1-1
A 45-year-old man presents with dysuria and urinary frequency. Initial urinary
tests reveal microscopic haematuria and sterile pyuria. A second 84-year-old man
presents with night sweats and a swelling in his loin.
1. Describe the images shown and the likely diagnosis.
2. What are the macroscopic changes seen in the kidney and ureter in this
condition?
3. What other fi ndings may be present on plain fi lm and intravenous urography in
this condition?
4. Describe the appearances seen in the kidney in Fig. 2.7.3 and the likely
diagnosis.
 
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Answers to Case 1-1-1
1. Figure 1-1-.1a,b are two IVU fi lms taken 4 months apart and show marked abnormality
of both renal collecting systems and left ureter. The left kidney shows
blunted, dilated calyces and the left ureter demonstrates an irregular ‘jagged’
contour with alternating strictures and dilatations. The right kidney shows dilated
calyces secondary to infundibular strictures, and cephalic retraction of an atrophic
renal pelvis. The appearances are highly suspicious for renal and ureteric
tuberculosis. Figure 1-1-1a is an axial and Fig. 1-1-1a,b a coronal contrast enhanced
CT of the older man showing a calcifi ed and atropic right renal parenchyma with
an associated fl uid collection involving the posterior abdominal wall. Aspiration
of the fl uid collection and culture revealed mycobacterium bovis.
2. The classic fi ndings of renal tuberculosis include parenchymal destruction and
scarring with associated cavity formation. Granuloma formation leads to parenchymal
masses and fi brosis with secondary strictures of the ureters and collecting
systems. The organisms reach the kidney through haematogenous spread,
and then propagate distally down the ureters to the bladder.
3. Plain abdominal radiographs demonstrate a wide variety of calcifi cation ranging
from amorphous granular calcifi cation to dense punctuate calcifi cation. In endstage
renal TB, intravenous urography often shows a shrunken hydronephrotic
kidney or complete absence of function (autonephrectomy). Chest radiographs
show evidence of active or healed tuberculosis in only 30%.
4. In Fig. 1-1-3 the kidney shows loss of parenchyma at the lower pole and replacement
by caseous tissue. Microscopy revealed caseous granuloma and acid fast
bacilli on Zeihl-Neelsen staining

Gibson MS, Puckett ML, Shelly ME. Renal tuberculosis. Radiographics .
2004;24:251–256

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