A 35-year-old female patient presented with painful gross hematuria associated with clots and burning micturition for a duration of 1 month. She also reported urgency, incontinence, and nocturia. She had a history of lower segment cesarean section done 8 months previously. There was no history of fever or other associated comorbidity. The general examination was unremarkable. Figure 1 shows the cytological features of three consecutive urine samples in Giemsa- and Pap-stained smears.
What is your interpretation?
Tuberculosis of urinary tract
Urothelial changes with treatment effect
Malignancy
Cystitis cystica glandularis.
The correct cytopathological interpretation is (a) Urinary tract tuberculosis.
Three consecutive urine samples showed the presence of epithelioid cell granulomas and multinucleated giant cells along with reactive urothelial cells and inflammatory cells [Figure 1a-c]. Special stain for acid-fast bacilli (AFB) was positive [Figure 1d], thereby confirming the diagnosis of tuberculosis. The reverse transcription polymerase chain reaction and cartridge-based nucleic acid amplification test of the urine sample were also positive. The patient was immediately started on antitubercular therapy, to which she responded well.
Ultrasonography for kidney, ureter, and urinary bladder revealed a mid-pole, well-defined, cortical hyperechoic space-occupying lesion (SOL) measuring 7x8x4 mm suggestive of hemangioma. A focal concretion and right-sided mild-to-moderate hydroureteronephrosis were present. Urinary bladder showed circumferentially thickened wall. Contrast-enhanced computed tomography revealed similar findings [Figure 2a and b].
Q2. What is the most common route of infection in renal tuberculosis?
Ascending spread
Hematogenous
Lymphatic spread
Direct invasion.
Q3. In genitourinary TB, which one of the following is true ?
Sterile pyuria is a consistent finding
AFB in early morning sample is always positive.
Most common site is pelvis
It is the commonest cause of pyelonephritis.
Q4. Golf hole ureter is seen in:-
Ureteric calculus
Ureteral polyp
Tuberculosis of ureter
Retroperitoneal fibrosis.
Q5. Which of the following considered as reliable diagnostic modalities for urinary tract tuberculosis?
ZN staining and cultures isolation for Mtb in urine,
PCR for Mtb,
Imaging studies,
Histopathological evidence for TB
All of the above.
Q2. b; Q3. a; Q4. c; Q5. e
Q2.b Genitourinary tuberculosis (GUTB) is mostly secondary to pulmonary infection. Renal TB is a chronic process that can start many years after the initial lung infection.
Q3. a Sterile pyuria is the rule. Tubercle bacilli can be identified on AFB staining of 24 h urine specimen or the first morning urine sample collected on 3 successive days. AFB staining is positive in about 60% of the cases. The most common site of GUTB is kidney. The most common cause of pyelonephritis is E. coli.
Q4. c Fibrosis due to Mycobacterium tuberculosis (Mtb) usually starts around the ureter and causes pull at the ureter leading to a strictured, dilated, and rigid mouthed ureter called as golf hole ureter.
Q5. e The most common procedures used for diagnosis of urinary tract tuberculosis include: (1) Urine cytology smears examination, (2) Ziehl-Neelsen (ZN) staining and cultures isolation for Mtb in urine, (3) PCR for Mtb, (4) imaging studies, and (4) histopathological evidence for TB.